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' SAN JOAQUIN COU�`PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALT*-4IVS10N <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T Don Ave. Pum Station N' A <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> Don Avenue N/A <br /> & <br /> CITY STATE 21P CODE # of TANKS <br /> 1 <br /> " Stockton Ca. Ca. 95202 at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L City Of Stockton John Fukomoto <br /> I <br /> APPLICANT PHONE # WITH AREA CODE <br /> A MAILINQ11poRFss El Dorado St. (209) 944-N29 <br /> N 41`J �J STATE 21P CODE TYPE of APPLICATION <br /> T CITY <br /> Stockton Ca. 95202 (Closure, Installation, etc.)C osure <br /> TOTAL <br /> 1986MJamarry <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.005 <br /> A <br /> C 5 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX <br /> I <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) $170/TANK <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply p by fee for <br /> Aeach year applicable) 5 <br /> C <br /> 1 TANK PENALTY FEES ASSESSED 10(XX XXXX S <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Cade, Section 25287 <br /> T <br /> Y N 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 = $78.00/hour (3 hours minimum/TANK) # TANK(s)_ _ X $234.00 = f 234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minim n/FACILITY) = 5234.00 minimum 5 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.O. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimANFACILITY) = S624.00 mini mm S <br /> R REPAIR FEE (workplan Review & Construction Inspections) TANK I.O. $(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) _ X 5234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 5234.00 mini mun S <br /> R <br /> PIPING REPAIR FEE = $78.00/hour (3 hours minimvVFACILITY) 5234.00 minimum f <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 5 <br /> 5 <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = S78.00/hr $ <br /> �} TOTAL DUE $ 234.00 <br /> FOR OFFICE USE <br /> »':xStiLaES ". iG" 0` .m'{) S'-C' Sl A` 1'RA `E" ;i <br /> a N <br /> ... : ..... .... pD(�2 Uzi o.3..31. .5.._ .y............ <. ..I.�X1 �.� ' ;� :�. . :::'M;: <br /> .;�saw:wv,aram.as:mw:w a.,m.RwPWY�oraai.:raszs:ws.was�essasawnarasrrm�ararsrr.,wmrar+,xsawswarasaasar,r,owwaraa.r..arrrmsrrrNrw <br /> EN 23 032 (REVISED 3.1-931 <br />