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SAN JOAQUIN C,_ r PUBLIC HEALTH SERVVCES -'ENVIRONMENTAL HE D VS1dl� (S <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> IIDon Ave. Pum Station N A <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> B <br /> Don Avenue N/A <br /> CITY STATE ZIP CODE I # Of TANKS <br /> P 5202 Stockton Ca. Ca. 9at SITE 1 <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L City Of Stockton John Fukomoto <br /> I <br /> C MAILINDRESS APPLICANT PHONE # WITH AREA CODE <br /> A 3A N. El Dorado St. (209) 944-8829 <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> Stockton Cd. 95202 (CLosure, Installation, etc.)Closure <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A $ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %X%% I xxxx S <br /> V TANK FEE = 450.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks 1986 1987 1988 1989 1990 1991 111992 1993 1994 1995 1996 <br /> F (multiply M byfee for <br /> A each year applicable) $ <br /> C <br /> 1 TANK PENALTY FEES ASSESSED XXXX X)CX% $ <br /> l <br /> I STATE SURCHARGE • $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> r # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> s <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE - 578.00/hour (3 hours minimum/TANK) # TANK(s) 1 X $234.00 = S 234:00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 6 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) • S234.00 minimum S <br /> P I INSTALLATION PLAN CHECK (Plan Review E Construction Inspections) TANK I.D. #(a) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minim uVFACILITY) $624.00 minimum 5 <br /> R REPAIR FEE (Workplan Review d Construction Inspections) TANK 1.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE • 578.00/hour (3 hours min iaua/TANK) # TANK(s) _ X 5234.00 S <br /> A <br /> 1 TANK RETROFIT REPAIR FEE • $78.00/hour (3 hours min./FACILITY) • $234.00 minimus i <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours mininuNFAC(l(TY) • 5234.00 minimus n s <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION • S78.00/hr s <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE 0/hr S <br /> RECEIV.ED! TOTAL DUE $ 234.00 <br /> 1 <br /> FOR OFFICE USE ONLY AUG Z U 99J <br /> _ ... ............................................................................................................................................................................................................................._...._................ <br /> '""." ��'Ynne� <br /> s ENVIRONMEN L HEALTH DIMS A <br /> a. <br /> ........................ .................. _._.._._.... .................................. . ......_. ... ........_.......................... ...................._................ <br /> _....._..... <br /> .....; <br /> ;a� xaYrwris:.r"•ir�ia+iA swA�w�a'rsais i.Aianw.ais:ra wwommmnnlum:s'mir wrreria:A`an:s'�isi:ti•a"wwrm'�+Fm�i waw:Awaw.luw`r:r+nu <br /> EN 23 032 (REVISED 3-1-931 <br />