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77 <br /> SA' :Aaj[X COUNTY PUBLIC HEALTH SERVICES _ <br /> v, %wENVIRCIUIEHTAI HEALTH DlViS ICN <br /> UNDERGROUND STORAGE TANK PRCGRAM - FEE UCRKSHE ET <br /> SITE NAME - I FACILITY CCNTACT NAME <br /> ROEK BROS. (AUTOMEISTER) DON ROEK <br /> ALI LI TY AOORL-SS SITE PHONE $ with AREA CME <br /> CITY STATE ZIP CCOE ! of TANKS <br /> w Y STOCKTON CA 95205 at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CCNTACT NAME <br /> P WESTERN METER SERVICE, INC. WILLIAM E. MESSICK <br /> ] <br /> ( MAILING ACORESS APPLICANT PHONE $ WITH AREA CODE <br /> C 2735 TEEPEE DR. STE. E — <br /> A <br /> B [ITT STATE ZIP CCOE TYPE of APPLICATION <br /> STOCKTGN, CA 95205 elcsCRE, INsruurtal, ate. REMOVAL <br /> TOTAL <br /> A <br /> 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) • $100.00 <br /> s <br /> I <br /> E TANK FEE • SSO.00RAHK (prior to January 7,1991) 5170/TANK (atter January 1, 1991) <br /> F ! To ._- ---- - 14E6 6587 1988 119E9 ( 1990 1991 1992 1993 11994 1995 1996 <br /> nki� <br /> A (eultlply ! try fee for <br /> C each year appltceble) S <br /> I <br /> L $TAr$ WRCNAao$ • $56.00 each TANK (Due every 5 years) See California H S S Code, Section 25237 _I <br /> I <br /> J Tanks x 256.00 1586 through 1990 1991 through 1996 a <br /> T (enter <br /> PERMAYENT CLOAIRE (Removal or Authorized Closure-in-Place) I TANK I.D. !(s) lii <br /> C <br /> L CLOSURE FEE • S53.00 per hour (3 hours minimi per TANK) ! TANK(s)�_ % 5159.00 =159-00 <br /> 0 <br /> 5 <br /> U TEYPCRART CLOSURE (A one-time permit, for review/inspectiorS) TANK I.D. !(s) <br /> R <br /> E TEMPORARY CLOSURE FEE 5150.00 each TANK ! TAHK(s) _ % 5150.00 = S <br /> i <br /> P PWI CHECK (Instal. Plan Review d Construction Inspections) TANK I.D. S(s) <br /> L <br /> A <br /> X PLAN CHECK FEE - 553.00 per hour (8 hours minima per Facility) • S424.00 minims$ 1 �. <br /> a REPAIR FEE (workplan review i cerstruetion imPeetiors) TANK I.O. S(s) <br /> P TANK REPAIR FEE • S53.00 per how (3 hours miniaamrTANK) ! TANK(s) _ X 5159.00 = 1 <br /> A i <br /> I <br /> R PIPING REPAIR FEE • $53.00 per hour (3 hour miniaue per facility • 1159.00) S <br /> II <br /> N TRANSFER FEE $20.00 <br /> jLJNALjrrHCRIZ--c0E EVALUATION 553.00/hrCCNAR.TATICH FEE S53.00/hrFEE • 553.00/M 1 <br /> g � TOTAL DUE SCFFICE USE ONLY _ __ai— _--+iaes .eF, p��1 —� �I LCPL..LC,U ^ N1L a�l-n] aLlL1 VLJ OT w,1.0 ALLCr L a <br /> I <br /> s iia.r/n v�� 7/l�14> <br /> rr:rarer:•isairrrrra+si srrrrresrsr serene rY••rrsrs rrrsrrrrr <br /> FH 73 032 (REV 4,8,91) ft .Pace 11' <br />