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New ..i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM -FEE WORKSHEET <br /> I FACILITY SITE NAME Zoya 0. Bryner FACILITY CONTACT NAME John Bavanda <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 9- <br /> 764 E. F3azelton St. N A <br /> CITY I STATE ZIP CODE # of TANKS <br /> A Stockton at SITE 1 <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L Zoya 0. Bryner John Bavanda <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A 7 Cheryl P1. <br /> M <br /> T CITY Menlo Park, TATE 921E,CADE TYPE of APPLICATION <br /> 4UL7 (closure, Installation, etc.) Removal <br /> TOTAL <br /> A TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> T # Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> I (multiply 8Ty fee for <br /> V each year applicable) XXXX %XXX XXxx XXXX %XXX 5 <br /> E S <br /> TANK PENALTY FEES ASSESSED I %XXX XXX% XXXX XX%X XXXX <br /> S <br /> [ STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California N & S Code, Section 25287 <br /> T <br /> E # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> 0 CLOSURE FEE = 878.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = 52'14 on <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 6 Inspections) TANK I.D. #(a) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) $234.00 minimus 5 <br /> PINSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimm/FACILITY) = 5624.00 mini mum 5 <br /> R REPAIR FEE (Workplan Review R Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> AS <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = S234.00 mini mun <br /> RS <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimMFACILITY) = $234.00 minimus <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> 1 <br /> ClCONSULTATION FEE = S78.001hr SAMPLING INSPECTION FEE = S78.00/hr $ <br /> TOTAL DUE 346.00 <br /> ...... err:— ............._-::::._.._— ._.. _—--�::_ <br /> SUE.E.P.�...il.... ....C�dlipU'T�A....#- -IDC-CbtiE_..._tiTSTttiCiE-�-AN�l7dT-'RT=c`EIV'�I�rtdExK'-#/CA�il—i--.RECETVE6 AY OATS E"tE.C.. . . ._ <br /> 'a .. . .. .._—. ._. .. ::::-- ;:.sem— <br /> EH 23 046 (Revised 9/11/96) Page 11 <br />