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a <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> • UNDERGROUND 510RAGE TANK PROGRAM • FEE WORKSHEET <br /> f AriLtTY SITE NAME FACILITY CONTACT NAME <br /> f <br /> " Fryin Knat Al Williamson 209 911 6810 <br /> D <br /> I FACILITY ADDRESS SITE PHONE Y with AREA CODE <br /> L 26422 N KennEfick Rd 209 368 2808 <br /> I <br /> I CITY STATE ZIP CODE M of TANKS <br /> T at SITE <br /> A APPIC T/V LLI N E APPLICANT CONTACT "HE <br /> P LA "J1 'Y RDmoval <br /> P 00 N 99 # 2o6 RZ GF/, LL �ati$� ar� <br /> L <br /> 1 NAILING ADDRESS APPLICANT PHONE M WITH AREA LODE <br /> D 00 N H ' 206 1209 931 6810 95212 <br /> A <br /> 0 CITYSPATE ZIP CODE TYPE of APPLICATION <br /> T Stockton Oa 95212 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 /> f <br /> I <br /> V <br /> L TANK FEE $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F e IaNs 1986 1987 1988 .1984 1990 1991 1 1992 1993 1994 1995 1996 <br /> A (Multiply y t fes for <br /> C each year ai* lcabl e) $ <br /> U SIAfE SURCHARGE $56.00 each TANK (Due every 5 years) See California M 8 S Cala, Section 25287 <br /> I <br /> I s Tanks A $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter mmault and year) <br /> S <br /> PLRI(ANENT CLOSURE (Removal or Authorized Closurc-In-Place) TANK I.D. tl(s) <br /> 1E1MEJ <br /> e <br /> CLOSURE FEE • $53.00 per hr (3 hours minimum per TANK) Y TANK(s)�_ % $159.00 <br /> TEMPORARY CLOSURE (A onetime permit, for rwiew/incpectiorm) TANK 1-D. M(s))TEMYg1ARY CLOSURE FEE • $150.00 each TANK Y TANK(s) X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review i Construction Inspection$) TANK I.D. Y(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) • 5424.00 mi nimua $ <br /> R REPAIR FEE (workplan review i construction inspections) TANK 1•D. Y(s) <br /> E <br /> P TANK REPAIR FEE i $53.00 per hour (S hours miniNANK) Y TANK(s) X $159.00 a f <br /> m/TA <br /> A <br /> I S <br /> R PIPING REPAIR FEE • $53.00 per hour (3 hour minimum per facility = $159.00) <br /> M TRANSFER FEE • $20.00 UNAUTHORIZED RELEASE EVALUATION • $53.00/hr $ <br /> Is <br /> C CONSULTATION FEE _ $53.00/hr SAMPLING INSPECTION FEE = 553.00/hr $ <br /> TOTAL OUE 5-9-0 <br /> OFFICE USE ONLY <br /> _ ...•... .;i:w:iv:»:i:r:�:i:w+:w::::r:+rx:z:k': <br /> :w 1'GE`EPS"Yre OF�WE111 t00�°mlz�) ` `S`PwLr43 �C1'r11"•` E rllwCr(1m)"m Fmrw a�`iSYE`eR �L Urarw� <br /> ra.wrmFrrarrrrrrrrwrAerrr"�:ei�.AiFrr.mewrrrrmrerrrmimr rrrmrerrseat aWNrrmmrr <br />