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, <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1 UNDERGROUND STORAGE TANK PROGRAM -FEE WORKSHEET <br /> I FACILITY SITE NAMLEODI LInUOR gt FOOD STORE FACILILI(,PC�I ACrTlt��t <br /> T ff11PP 11�� l> I` tt'' <br /> E FACILITY <br /> & ADDRESSITE P lw3.i5$225 WEST LOCKFORD R��3ppE <br /> CITY STATE ZIP CODE # of TANKS <br /> P LODI CA (%MD$n at SITE 1 <br /> L APPLICANT/BILLING NAMEL & M CONSTRUCTION CONTACT NAMRRY A. LOCKREM <br /> I <br /> C MAILING AD RE SS <br /> APPLICANT PHONE # WITH AREA CODE <br /> A 960 KIEFER BLV[ . SUITF 0 <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> ISACRA11 N CA %,*@8t (Closure, Installation, etc.) CLOSURE <br /> TOTAL <br /> A TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> C <br /> T # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> I (multiplyEby—fee for <br /> V each year applicable) XXXX XXXX XXXX XXXX XXXX $ <br /> E <br /> TANK PENALTY FEES ASSESSED XXXX XXXX I XXXX XXXX XXXX $ <br /> S <br /> T STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 1AA&I5 �o <br /> E # Tanks x $56.00 1986 through 1990 1991 through 1996 e <br /> (Enter amount and year) <br /> 56.00 $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(S) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ <br /> TOTAL DUE 112.00 <br /> 1G...::....:..:..::«QN;I.X.....::::-:. ::::::-:::-:::::::::::::::::::m.:.........................................._......_............................._. _._._ _. .._. <br /> .............................................:s:: ::;:a:s:::::::::s ::::::s <br /> ...................:: :s:t:::::::::>a:-a:::::::::: :¢sa:::s::;: a:: :::::::::::::::::::::«:::::::::::::::::: a:::ss¢:::::::::-as::::sa:::::::t ts:::::::::::s:sss:::::::::is::a :::s:a:t:sst::s::t;::::::::....................... <br /> :« SWEEPS # COMPUTER # LOC CODE ()ISl CODE AMOUNT RECI_•1VED CFIECK••W%CI1SH•••• ..........RECEIVED BY••••••••••••............. <br /> DAVE RECEIVEDN. <br /> t <br /> ;33 <br /> M <br /> «: <br /> ......::::::::::::::: : «.................._..................._......................................._.....................__........._...... <br /> .........................................................................._.:«::..:......::::«:::«:::::::: .___._.... <br /> EH 23 046 (Revised 7/10/96) • Page 11 • <br />