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APR 19 1993 <br /> EN P�ERMITIS RVICES <br /> HEALTH <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> FNONE WILLIAM VALENCIA <br /> I FACILITY ADDRESS 3507 STEVINSON STREET SITE PHONE # with AREA CODE NONE <br /> L <br /> T CITY ,s,stTATE 2 # of TANKS <br /> Y <br /> STOCKTON l,A7LU� at sITE TWO (Z) <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P WILLIAM VALENCIA WILLIAM VALENCIA <br /> I MAILING ADDRESS 912 S. CALIFORNIA ST, APPLICANT PNONE # WITH AREA CODE <br /> C <br /> A ATE 21P TYPE of APPLICATION <br /> "r CITY STOCKTON to 9ST65 CLOSURE, INSTALLATION, etc. REMOVAL <br /> TOTAL <br /> A 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) • t100.00 $ <br /> I <br /> V <br /> E TANK FEE 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F 0 Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply �Gy--fee for 5 <br /> C each year applicable) <br /> L STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See California H b S Code, Section 25287 <br /> i # Tanks z $56.00 1986 through 1990 1 1991 through 1996 <br /> Y (enter amount and year) S <br /> PERMANENT CLOSUR (Removal or Authorized Closure-in-Place) TTI.D. #(s) <br /> L CLOSURE FEE a .00 per hour (3 hours minimum per TANK) # TANK(s)�_ X $ 00 t Z3�- <br /> a <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TAMK I.D. #(s) <br /> R <br /> E� <br /> TEMPORARY CLOSURE FEE - $150.00 each TANK # TANK(s) _ X Y950.00 � 5 <br /> P1 PLAN CHECK (Install. Plan Review 8 Construction Inspections) TAMK LD. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minima per Facility) $424.00 minimus $ <br /> R REPAIR FEE (workplan review i construction inspections) TANK I.D. #(s) <br /> P TANK REPAIR FEE _ $53.00 per hour (3 hours minimum/TAN K) # iANK(s) X $159.00 $ <br /> A <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimm per facility = $159.00) $ <br /> M TRANSFER FEE $20.00 UNAUTHORIZED RELEASE EVALUATION • $53.00/hr $ <br /> 1 <br /> C CONSULTATION FEE _ $53.00/hr SAMPLING INSPECTION FEE . $53.00/hr $ <br /> TOTAL DUE <br /> nr 9 1ro IMr,QNL,— <br /> !' "s`CiE'EP"S CCMrUYER CDtiE 3Y COti (SUIT$ kCVD CAEC M- 1 VERY �"' BAI ECEIQED <br /> x <br /> _ <br /> E8 23 032 (Revised 4/8/91) Page 11 <br />