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tES <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENT <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY CONTACT NAME r+—rl 17 1991 <br /> Leland Rosenau Leland Rosenau <br /> SITE PHONE / with AR $ ' HEALTH SFRvICES <br /> (209) 33/Ei�b'RMMENTAL HEALTH DIVISION <br /> 5625 N. Davis Rd. I jj ppDp <br /> CS(;aE 2y� 4� at SI TE0 of NKS 1 <br /> A ANAME APPLICANT CONTACT NAME <br /> P nau Jim Thorpe Oil Inc. / Contractor <br /> P [ <br /> L APPLICANT PHONE 0 WITH AREA CODE <br /> I MAILING ADDRESS (209) 334-6200 <br /> 15625 N. Davis Rd. <br /> A STATE ZIP CODE TYPE of APPLICATION <br /> N CITY Ca 5240 CLOSURE, INSTALLATION, ate. Removal. <br /> T Lodi i <br /> TOTAL I <br /> A 1986 1987 1988 1989 1990 �I <br /> C <br /> 1 ANNUAL FACILITY FEE (Prior to January 1, 1991) • !100.00 $ N/A <br /> I <br /> V $170/TANK (after January 1, 1991) <br /> E TANK FEE • 150.00/TANK (prior to January 10991) <br /> F / forks • 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (m(tl Ply fee for S N/A <br /> c each year applicable) <br /> I 25287 <br /> L STATE SURCHARGE • s56.00 each TANK (Due every S years) fee California N f S Code, Section <br /> 1 1986 through 1990 1991 through 1996 <br /> T 0 Tanka__ n $56.00 <br /> Y (enter rnotMt and year) f N A <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. f(a) <br /> C <br /> L CLOSURE FEE • $53.00 per hour (3 hours minimum per TANK) / TANK(s) 1 % $159.00 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/Inspectlons) LANK I.D. f(e) <br /> RN TANK(s) _ % $150.00 • S <br /> E TEMPORARY CLOSURE FEE • $150.00 each TANK <br /> P PLAN CHECK (Inn tall. Plan Review d Core tructlon Inspections) TANK 1.0. /(a) <br /> L <br /> Af <br /> N PLAN CHECK FEE . $53.00 per hour (8 hours minlmm per Faclll ty) • $424.00 minlmm <br /> R REPAIR FEE (workplan review Z construction Inspections) TANK 1.D. $(s) <br /> Ef <br /> P TANK REPAIR FEE • $53.00 per hour (3 hours minlaxWTANK) K TANK(s) % $159.00 <br /> A <br /> If <br /> R PIPING REPAIR FEE • $53.00 per hour 0 hour mini" per facility • $159.00) <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> SFEE • S5i. hr FEE = f 53.00/hr <br /> C FEE • $53.00/hr 00/ <br /> TOTAL DUE $ 15 .00 <br /> OFFICE USE ONLY ............................................................................................................................................................................................... <br /> .._ <br /> .......».........».....»..».._........_,w .fat tea. .j�i . <br /> MMmWMOffn <br /> •��•l(11: W UICU1e WMu1Nn mCW W. �ASM W\n�/ttL�l l�VkU arm U111EIVta ~ <br /> M MM.•IW MI I.,1 WMII.I TIM II,Ie•M MM W e.,,,W Ml.r W I.M Y.W M IMM W.M,W W IWM W IW.Y I...,,IM I,YM I.M I,•WM.M.1,,,.,1•,MM..TM W <br /> mYMMae MAYaIAM AmN Ya WmMll MlnratM NMR MNAWWAa M•,NAe IIIImrN/la lAlM me Me eaMIaMMMNw AWaAM AMY AMnaW MM as m••Ulr mlalW rmwMWa na•ararmsmrmw Wa <br /> Paaa 1 1 <br /> EN 23 032 (REV 1/10/911 ft `� <br />