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SAN JCACA COJNTT PUBLIC HEALTH SERVICES <br /> Em%wd MENTAL HEALTH OIV1SICN <br /> UNDERGROUND STORAGE TANK 7RCGRAM - FEE L'CRKSHEET <br /> I FACILITY CHTACT NAME <br /> SITE NAME <br /> ROEK BROS. (AOTOMEISTLR) DON ROEK <br /> SITE PHCNE Y with AREA CME <br /> ACILITT ADDRESS <br /> STATE ZIP CCOE at SITE(TANKS <br /> SPOCKTON <br /> CITY CA 95205 <br /> r <br /> APPLICANT [CHTACT NAME <br /> A APPL(CANT/BILLING NAME <br /> WESTERN METER SERVICE, INC. WILL <br /> E. MESSICK <br /> APPLICANT PHCNE 7 WITH AREA CODE <br /> I NAILING ADDRESS —6124 <br /> CA2735 TEEPEE DR. S E. <br /> [ITT STATE ZIP CCE TYPE of APPLICATION REMOVAL <br /> STOCKTON, <br /> CA 195205 CLOSU'R`E• INSTALLATICH, etc. <br /> TOTAL <br /> A I 1986 1987 1988 1989 1990 <br /> C 1991) • 5100.00 <br /> T ANNUALIACILITT FEE (Prior to January 1, S <br /> I <br /> V1170/TANK (after January 1, 1991) <br /> E TANK FEE + SSO.00/TANK (prior to Jaruary 1,1991) <br /> -r 1 Tanks • 1986 1987 1988 1989 11990 1991 1992 1993 11994 1995 1996 <br /> A (au(tiplyY try tea for I I S <br /> C each year aCOl leahle) <br /> I <br /> L STATESURCHAR� • 556.00 each TANK (Due every 5 years) Sr_ California H S S Code, Section 2529 <br /> I 1991 2hrcuSh 1996 <br /> I Tanks X 556.CO 1986 throurh 1990 <br /> T (enter t and year) SG 2 /�a•DO <br /> S � <br /> PE..I.MMEHT CLCSCRE (Removal or Authorized Closure-in-Plate) I TANK I.D. d(s) <br /> C 0 TANK(s) X 1159.00 • S. <br /> L CLOSURE FEE • 553.00 per hour (3 hours minimuts per TANK) _ <br /> 0 <br /> S <br /> UTC4pCRART CLOSURE (A one-time permit, for review/inspections) <br /> R ! TANK(s) —__ X 2150.00 • 2 <br /> E TEYPCRART CLOSI.'RE FEE • 2150.00 each TANK <br /> i PLAN CNECX (Install. Plan Review S Construction Inspections) TANK I.D. !(s) <br /> L <br /> A5424.00 minimum5 <br /> .4 PLAN CHECK FEE - S53-00 per hour (8 hours mini" per Facility) <br /> R REPAIR FEE (workplan review L ecestruccion Inspections) TANK I.O. s(s) <br /> P TANK REPAIR FEE • $53.00 per hour (3 hours miniaaaNTANK) ! TANK(s) X 2159.00 • 1 <br /> A <br /> I S <br /> I PIPING REPAIR FEE • S53.00 per hour 0 hour minlmua per facility - 1159.00) <br /> N TRANSFER FEE • 520.00 UHAUTHCRIZEED RELEASE EVALUATION - S53.00/hr S <br /> 1 <br /> S c • 153.00/hr <br /> CJISULTAT ICN FEE • 553.00/hr SAMPLING INSP_CTICN FEE S <br /> �( TOTAL DUE 1 <br /> CFFICE USE ONLY —____—_--�.---------------_— <br /> _ �yf �. ray qct yV IaaY�4}Y{,rrl, saai•r(VvTCA�Rfal�•a•! <br /> t:LGI Ill].�1 <br /> .1.11C•� ,MU. 1 C,U QAC i/l�] � aC1.C1 VC:! O� I LAIC IICVGI Ctl <br /> 3 3 /0710 ---- --7 Pdl yl <br /> w•�iwwswaw••!•�a.•irrr.arsias.wwrws+sr..,wswa.�wr+wwa.wa.r wear rawraar.w wnrar�.•►sa�w.� <br /> Pace 11' <br /> EN 23 M2 (REV 4/8/911 ft <br /> s� }SLP <br />