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ep <br /> SO." JOAQUIN COUNTY PUBLIC HEALTH SERVIC• <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME <br /> F FACILITY CONTACT NAME <br /> A M a M Automotive <br /> C Larr or Richard <br /> 1 FACILITY ADDRESS <br /> L0 >'ra9 SITE PHONE # with AREA CODE <br /> 1 <br /> T CITY <br /> y STATE ZIP CODE # of TANKS <br /> Tracy C 95 76 at SITE 2 <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> LP 4900 N H 99 r 206 Stkn Ca 9 212 <br /> Aln Williamson <br /> 1 MAILING ADDRESS <br /> CS,�ITle APPLICANT PHONE # WITH AREA CODE <br /> A 209 931 6810 <br /> N CITY <br /> T Stockton STATE ZIP CODE TYPE of APPLICATION <br /> 212 CLOSURE, INSTALLATION, etc. Removal <br /> A TOTAL <br /> C <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 1986 1987 1988 1989 1990 <br /> I <br /> V $ <br /> E TANK FEE $50.00/TANK (prior to January 1,1991) $170 TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 <br /> A (mnttipty 1992 1993 1994 1995 1996 <br /> p byby fee for i <br /> C each year applicable) \ <br /> I �� $ <br /> L STATE SURCHARGE _ $56.00 each TANK (Due e r�-s years) S Califo r�i .H 8 S Code, Section 25287 <br /> T # Tanks A $56.00 1986 [ ro gh 1990 <br /> Y (enter amount and year) 1991 through 1996 <br /> rte, V IiK <br /> C PERMANENT CLOSURE (Removal or Authorized Ctosure-in!P ce) `,J TANK I.D <br /> L CLOSURE FEE _ $53.00 per hour (3 hours mi nim.)m per TANKO�V # T(N1Kts) Z % $159.00 = g <br /> S ••��"" O <br /> U TEMPORARY CLOSURE (A one-time permit, for vAew/ins do <br /> R \TANA I.D. #(5) <br /> E TEMPORARY CLOSURE FEE _ $150.00 ch Nk "1 tl v �.� <br /> i # TANK(s) % 6150.00 = g <br /> P PLAN CHECK (Install. Plan Review C ns. ruc <br /> L o Insp •' [`ions) I TANK I.D. #(s) <br /> AJ <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours miniaum per Facility) _ $424.00 minimum <br /> $ <br /> R REPAIR FEE (workplan review 8 construction inspections) <br /> E TANK I.D. #(s) <br /> P TANK REPAIR FEE _ $53.00 per hour (3 hours mi nimum/TANK) # TANK(s) __ % $159.00 = <br /> A $ <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimm per facility - $159.00) <br /> $ T <br /> M TRANSFER FEE _ $20.00l� <br /> UNAUTNORI ZED RELEASE EVALUATION = $53.00/hr <br /> S $ �.✓' i. ��.: <br /> C CONSULTATION FEE = 553.00/hr <br /> SAMPLING INSPECTION FEE = 853.00/hr S <br /> OFFICE USE ONLY 1/ r Uj <br /> TOTAL DUE W �- <br /> ..... <br /> m»xS p'S•"vt�' COF(PUTc12a". m s. . x ux z.<"a„"°° . ..........wu«ess. ;:»> ;,m:x:o'e:» � <br /> a <br /> » R3c��1 <br /> ,;Fv =./911 tr • mnsamxmsmr:mmaaxarmamtmexnr.emottmxsxa¢auaaer <br /> Pace 11 <br />