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SAN JOAQUIN COUNTY T-.LIC HEALTH SERVICES - ENVIRONMENTAL HEALTH_ j10N N` y r <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET �/ <br /> 5 FACILITY SITE NAME FACILITY CONTACT NAME <br /> I A. Teichert & Son, Inc. Russ Broaddus <br /> T SITE PHONE # with AREA CODE <br /> -E FACILITY ADDRESS <br /> 103 North E Street 209-946-8580 <br /> 3 STATE ZIP CODE # of TANKS - <br /> clTr Stockton CA 95205 ac SITE 4 <br /> A <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME DEC 0 9 1998 <br /> L A. Teichert & Son, Inc. Geon a Takemori <br /> I APPLICANT PHONE # WITH AREA CODBMANJUAC;UINCOUNTY <br /> C MAILING ADDRESS 916-386-6916 PUBLIC HEP..LTH OE'AVICYS <br /> A P.O. BOX 15002 LNO:NNiENT hl <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CITY (Closure, Installation, etc.)Closure <br /> Sacramento CA 95851 <br /> TOTAL <br /> 1986 1987 11908 11989 1990 <br /> I ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 XXXX XXXX XXXX XXXX XXXX E X%XXXXXIT <br /> A <br /> cxxxx xxxx xxxx xxxx x%xx s x%xxxxxx <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I5170/TANK (After January 1, 1991) <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) <br /> E 1988 1969 1990 1991 11992 1993 1994 1995 11996 11997 1998 <br /> # tanks = <br /> F (multiply by fee for I S <br /> A each year applicable) XXXX <br /> XXXX %%X% %%X% XXXX I I t <br /> C <br /> 1 TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXX% %%XX <br /> L f <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 <br /> T 1988 through 1993 (556) 1993 through 1997 (556) 1998 <br /> Y # Tanks_ x 58.00 <br /> SURCHARGE FOR 1998 Xxxxxxxxxxxxxxxxxxxxxxxxxxx <br /> XXXXXXXX%XX%XXXXXXXXXXX S <br /> C PERMANENT CLOSURE (Removal or Authorized c(osure-in-Place) I TANK I.D. #(s) s468 . 00 <br /> L I # TANK(s)2 X 5234.00 = <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) 'A <br /> TANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review 5 inspections) . <br /> R t <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L PUBLIC HEALTH SE ICES <br /> A - <br /> S624,00 minimum ENVIRONMENTAL HF.ALT 91VIBION <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br /> R REPAIR FEE (Workplan Review d Construction Inspections) I TANK I.D. #(S) <br /> E # TANK(s) __ X 5234.00 = S <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /> A = 9234.00 minimae S <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br /> R = $234.00 minimum S <br /> PIPING REPAIR FEE = 578.00/hour (3 hours mi nimm/FACILITY) <br /> 1 I <br /> M TRANSFER FEE 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 5 <br /> 11 <br /> � I 5 <br /> S SAMPLING INSPECTION FEE = $78.00/hr <br /> C CONSULTATION FEE = 578.00/hr <br /> TOTAL DUE S <br /> FOFFICE <br /> OR <br /> SVEEPS # COMPUTER # LOC CODE DISI CODE AMOUNT RECEIVED I CHECK #/CASH RECEIV <br /> MI <br /> !Kf:!!Bpi!!!5f!FFFf:::!f:::e!_...1+^uJ'v0!!!BSC:nce^llv:_::F'r•.eiFf!!e:[Ei'e:i!iF:F-iiiBB°:::=i*:iii^'—!-_fiFr._. <br /> FN n nS7 TRFVISFD 1-12-98) laa.( �� <br />