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\I - <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />TOTAL DUE f <br />OFFICE USE ONLY <br />ER 23 032 (REV 1/10/911 ft Paae 11 <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />A <br />TELLI LIFT TRUCK SERVICE <br />ED GOTELLI <br />C <br />I <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />1856 NORTH Bgoomy <br />(2tjq) 46S <br />5609 <br />T <br />Y <br />CITYTE <br />TOCKTON <br />STA <br />ZIP CODE <br />95205 <br /># of TANKS <br />at SITE Two (2) <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />TELLI LIFT TRUCK SERVICE <br />ED GOTEL-I <br />L <br />I <br />NAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />856 NORTH BRIADWAY <br />209) 465 3609 <br />A <br />SyIATE <br />C..SPDE <br />PPLICATION <br />ofCLOSURE, IINSTALLATTIION, <br />T <br />TOCKTON <br />ITYPE <br />L�J7 <br />etc. CLOSURE <br />TOTAL <br />A <br />C <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />T <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />f <br />I <br />V <br />E <br />TANK FEE = $50.00/TANK (prior to January 1,1991) $170/TANK <br />(after <br />January <br />1, 1991) <br />F <br /># Tanks = <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 1991 <br />1992 1993 1 1994 <br />1 1995 <br />1996 <br />A <br />(multiply if by fee for <br />$ <br />C <br />each year applicable) <br />1 <br />L <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br />I <br />T <br /># Tanks z 556.00 <br />1986 through 1990 <br />1991 through 1996 <br />Y <br />(enter ion t and year) <br />$ <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TTANK I.D. #(s) <br />C <br />L <br />CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = <br />f <br />0 <br />' <br />S <br />U <br />TEMPORARY CLOSURE (A one-time permit, for review/inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $150.00 each TANK <br /># TANK(s) X $150.00 = <br />f <br />P <br />PLAN CHECK (Install Plan Review 8 Construction Irvspectlons) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE - $53.00 per hour (8 hours mini mm per Facility) = $424.00 minimum <br />f <br />R <br />REPAIR FEE (workplan review 8 construction inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) <br /># TANK(s) X $159.00 = <br />$ <br />_ <br />A <br />1 <br />R <br />PIPING REPAIR FEE _ $53.00 per hour (3 hour mini mm per facility = $159.00) <br />$ <br />UNAUTHORIZED RELEASE EVALUATION <br />SAMPLING INSPECTION <br />7CONSULTATIONS <br />1 I <br />S <br />C <br />I FEE = $53.00/hr <br />FEE = $53.00/hr <br />FEE = $ 53.00/hr <br />TOTAL DUE f <br />OFFICE USE ONLY <br />ER 23 032 (REV 1/10/911 ft Paae 11 <br />