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SAN JOAQUIN COUNIY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE IJORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> f <br /> A Ken Sasaki Ken Sasaki <br /> C <br /> 1 FACILITY ADDRESS SI T�20H011E twith <br /> 3t AREA CODE <br /> L 20021 N. Kennefick Rd. 9) <br /> 1 <br /> T CITY STATE ZIP CODE S of TANKS <br /> Y Acampo, ca. 95220 1 <br /> at SITE 3 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P Jim Thorpe Oil Inc. <br /> P Ken Sasaki <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 0 WITH AREA CODE <br /> C 20021 N. Kennefick Rd. 20 333-0422 <br /> A <br /> N CITY STALE 21P [ODE TYPE of APPLICATION <br /> T Acampo, ca. 95220 CLOSURE, INSTALLATION, etc. Removal <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> I 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) $170/TANK (after January 1, 1991) <br /> F 0 Tanks 1986 11987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply / by fee for <br /> c each year applicable) $ <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H S S Code, Sect[on 25287 <br /> IY <br /> Tanks x (56.00 1986 through 1990 1991 through 1996 <br /> T enter amount end year) <br /> S <br /> P( <br /> PERMANENT CLOSURE (Removal or Authorized Closure-In•Plece) TANK I.D. Y(s) <br /> C <br /> L CLOSURE FEE • $53.00 per hour (3 hours minimum per TANK) S TANK(s) 'A N $159.00 $ 477.00 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/Inspections) TANK I.D. S(a) <br /> R <br /> E TEMPORARY CLOSURE FEE • $150.00 each TANK M TANK(s) K $150.00 • f <br /> P PLAN CHECK (Ins tell. Plan Review S Coro truction Inspections) TANK I.O. M(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (a hours minimum per Facility) • S424.00 minimum f <br /> R REPAIR FEE (workplan review S construction Inspections) TANK i.D. S(a) <br /> E <br /> P TANK REPAIR FEE • $53.00 per hour (3 hours minimssNTANK) Y TANK(s) _ K $159.00 = $ <br /> A <br /> 1 <br /> R PIPING REPAIR FEE • $53.00 per hour (3 hour minimum per facility • $159.00) t <br /> M=:S5::30=O/hr <br /> UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C FEE _ $53.00/hr FEE f 53.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> __...._�.r..•.•w_...�_•.»_r_..... waw ae <br /> 5 www a�rExs ire =vrrr-�euE- ernr�ar �r�rs+�r,+s�wM ��ro�rvoy -u�r �u�r-w "a <br /> 1 �.1.:........... 1. .. . <br /> $ e>�. ....1L....... <br /> w eewwwwama wmw wemewwtrwww wwiwuiewawwmwwwwwwawwawwwai,�wawwwAwwwmwwwwmwwwwaww <br /> EN 25 032 (REV 1/10/911 It \/ Paae I 1 <br />