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l <br /> 1N JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET`/ <br /> FACILITY SITE NAME FACILITY CONTACT NAME �- <br /> A <br /> c HERMAN & HELEN'S MARINA INC. JERRY MATTHEWS <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE Z Uj C270 w= <br /> L 13135 W. EIGHT MILE ROAD 209-951-4634 W 9 f �'u,w I ' <br /> 1dc LU <br /> T CITY <br /> STATE ZIP CODE # of TANKS <br /> Y STOCKTON CA 95219 as s1rE 3 eXIII <br /> V Qw< <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME a M Q —'U ZE <br /> P Z- <br /> Q 7 <br /> L WARREN E. GOMES EXCAVATING INC. WARREN E. GOMES <br /> L -- j <br /> 1 MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE `w i <br /> L P.O. BOX 369 707-374-2881 <br /> A <br /> STATE Zlp LODE TYPE of APPLICATION <br /> T CITYSTATE <br /> VISTA CA 94571 CLOSURE, INSTALLATION, eta CLOSURE <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 i <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) - S100.00 <br /> 1 $ <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = _ 1986 1987 1988 1989 1 1990 [_!91_L1992 1993 1994 1995 1996 ` <br /> A (eultiply # by fee for <br /> C each year applicable) $ <br /> ESTATE <br /> RGE = $56.00 each TANK (Due every 5 years) See California H d S Code, Section 25287 <br /> x 556.00 1986 through 1990 1991 through 1996 <br /> t and year <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = S53.00 per hour (3 hours minimm per TANK) # TANK(s) 3 X $159.00 s 477.00 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 5150.00 each TANK # TANK(s) _ X 5150.00 = S <br /> P PUN CHECK (Install. Plan Review 6 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PIAN CHECK FEE $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum S <br /> R REPAIR FEE (workplan review & construction inspections) FTAM 1.D. #(s) <br /> E <br /> P TANK REPAIR FEE - $53.00 per hour (3 hours miniaxWTANK) NK(s) _ X $159.00 = 5 <br /> A <br /> I 5 <br /> R PIPING REPAIR FEE = S53.00 per hour (3 hour minimum per facility - 5159.00) <br /> M CCHSULTATICNS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> 5 <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE 5 <br /> OFFICE USE ONLYv�.t <br /> .............._..............................__................_............_......._......._.._.........._ <br /> _......»................__......_..__..__.._..__..._...._.»._._..._...._....._.........._........__.. a�_.�s_.s_i�_we_�p:�r_._sgs���._a�.�_{�_�~/i�i <br /> asni '-_irm� <br /> a a <br /> etjQV Yylal S ! ....................i <br /> fl�iatii�f W��=1=i AYlilli fw611�f1Mai Mf=III=.i�Ola1 McY1sMiMYtlllil/!ti{111=1.6A•to�aia�a�aaai lifl=R}/^iii il,a{=li MYi��i lt��r1r1Y1M of <br /> EH 23 (132 (REV 1/10/911 ft Paoe 11 <br />