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Sg - (-0/3 <br />SAN JOAQUINY PUBLIC HEALTH SERVICES - ENVIRONMENTAL H DIVSION <br />AGROUND <br />/fT��/ STORAGE TANK PROGRAM - FEE HORKSHEE /T/D / 0 <br />S <br />FACILITY SITE NAME <br />1986 1987 1488 1989 1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />FACILITY CONTACT NAME ! r C <br />I <br />. <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br />ANASTASIO' <br />S AM/PM <br />MINI MART <br />Jack AnasMjU'�#��� HeA� <br />T <br />E <br />FACILITY ADDRESS <br />R <br />E <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />SITE PHONE # with AREA <br />I <br />V <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />3425 Tracy <br />Blvd <br />(209) 835-1 <br />& <br /># Tanks = 1986 1987 1988 1989 <br />1990 1991 1992 1993 1994 1995 1996 <br />F <br />(multiply # by fee for <br />A <br />each year applicable) <br />S <br />CITY <br />C <br />STATE <br />ZIP CODE <br /># of TANKS <br />A <br />S <br />Trac <br />CA <br />95376 <br />at SITE <br />T <br />Y <br />Tanks x 556.00 <br />1986 through 1990 <br />P <br />APPLICANT/BILLING NAME <br />nter amount and year) <br />APPLICANT CONTACT NAME <br />ANASTASIO'S <br />AM/PM <br />MINI MART <br />Chester Bennett <br />I <br />C <br />MAILING ADDRESS <br />c/o TAIT & <br />ASSOCIATES, INC. <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />2880 Sunrise <br />Blvd, <br />#206 <br />(916) 635-2444 <br />N <br />T <br />CITT <br />STATE ZIP CODE ETYPE of APPLICATION <br />Rancho Cordova <br />CA 95742 Closure, Installation, etc.) Closure <br />I <br />TOTAL <br />C <br />PER NENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s <br />1986 1987 1488 1989 1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />CL RE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 <br />A <br />. <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br />S <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum. S <br />S <br />U <br />TE RARY CLOSURE (Plan Review & Inspections) TANK I.D. (s) <br />C <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />R <br />E <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX X700( S <br />I <br />V <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br /># Tanks = 1986 1987 1988 1989 <br />1990 1991 1992 1993 1994 1995 1996 <br />F <br />(multiply # by fee for <br />A <br />each year applicable) <br />S <br />C <br />I <br />TANK PENALTY FEES ASSESSED XXXX XXXX <br />S <br />L <br />I <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) <br />See California H & S Code, Section 25287 <br />T <br />Y <br />Tanks x 556.00 <br />1986 through 1990 <br />1991 through 1996 <br />nter amount and year) <br />S <br />C <br />PER NENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s <br />TANK I.D. #(s) <br />L <br />0 <br />CL RE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 <br />S <br />. <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum. S <br />S <br />U <br />TE RARY CLOSURE (Plan Review & Inspections) TANK I.D. (s) <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />R <br />E <br />JTE ORARY CLOSURE FEE - 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum <br />S <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />. <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum. S <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />. <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= 5234.00 minimus S <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) <br />= $234.00 minimus $ <br />M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br />I <br />S <br />C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr $ <br />FOR OFFICE USE ONLY <br />TOTAL DUE S / / �" <br />MVA MEM10 M <br />EH 23 032 (REVISED 3-1-931 W Pace 11 <br />