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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> '-UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> r7E <br /> ILITY SITE NAME FACILITY CONTACT NAME <br /> n & Dorothy Kienitz Don Kienitz <br /> C <br /> ILITY ADDRESS SITE PHONE # with AREA CODE <br /> 75 E . Jones 209-785-3960 <br /> STATE ZIP CODE # of TANKS <br /> al0 CA 95320 at SITELICANT/BILLING NAME APPLICANT CONTACT NAME <br /> Equipment ServiceKeith A . Tallia <br /> ING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> Box 950 209-754- 1808 <br /> SC ATE ZIP CODE TYPE of APPLICATION <br /> Andreas 95249 CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> I f <br /> V <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (m Ltiply # by fee for <br /> C each year applicable) $ <br /> 1 <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> 1 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> f <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) 1 X $159.00 = S 159 . 00 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/in specti ors) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S150.00 each TANK # TANK(s) X $150.00 = f <br /> P PLAN CHECK (Install. Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours mini mm per Facility) = S424.00 minimum f <br /> R REPAIR FEE (workplan review 8 construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = f <br /> A <br /> 1 <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility - $159.00) $ <br /> ICCS, CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> FEE _ $53.00/hr FEE = $53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S 159 . 00 <br /> OFFICE USE ONLY <br /> M»a+s..se.z.ee.....e..=e.a..r«.�...eye.=..s...s..s.»::i:.a..x..x.ee.ze..ee»..e....e..ze..esee.e. xe.wa......ese.w...a.zaae....ee.x...ee...e...ee.a.......n.x..... <br /> wswawaa`ss"`=MswsrexA i.w w�r"sr ws'�arar�+s'1 f C ( .... �� :l I 1 �I�A — —c' a <br /> a.. ... . ..... . J .... ,;r.«».» ,;,a..:�»' l .. »aA,.«»,:»:»;.e;::».r._.( 31�,c;,»1,.;.:.,;;;,� <br /> EN 23 032 (REV 1/10/91) ft Paae 11 <br />