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4 <br /> SAN JOAQUIN COUNTY PU911C HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAH FEE WORKSHEET <br /> FACILITY :ITE NAME FACILITY CONTACT NAME <br /> AMildred De Vincenzi Bob Hesseltine <br /> FACIIITr ADDRESS SITE PHONE 0 with AREA CODE <br /> L 21167 N. TreLliewa Rd. 12no) 931-3486 <br /> I STATE IIP CODE 0 of TANKS <br /> Cllr Acampo, Ca. 95220 at SITE 1 <br /> A APPLICANT/11111.1110 NAHE APPLICANT CONTACT MAHE <br /> P <br /> P Mildred De Vincenzi same <br /> L <br /> HAILING ADDRESS <br /> C 12267 E. Eight Mile Rd. APPLICANT <br /> 931 3486WITH REA CODE <br /> A STATE ZIP CODE P11POE of APPLICATION <br /> N CITY SURE, INSTALLATION, etc Removal <br /> TStockLQ[i, C@ <br /> TOTAL <br /> A <br /> C 1984 1987 1988 1489 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) ■ $100 00 <br /> t <br /> 1 <br /> Y <br /> E TANK FEE ■ 150 OD/TANK (prior to January 1,1991) 5170/1ANK (after January 1, 1491} <br /> F 0 Tanks • 1986 198r 1988 1989 1990 1991 11992_1 1993 1 1994 1945 19961 <br /> A (multiply F-Gy fee for <br /> C each year applicable) S <br /> I <br /> I. STATE SURCHARGE ■ 156.00 each TANK (Due every 5 years) See Callforrnis H L S Code, Section 25287 <br /> I <br /> • T t Tanks x $56 00 1986 through 1990 1991 through 1596 <br /> Y (enter amount and year) <br /> t <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I D 0(a) 464 <br /> C --+ <br /> L CtOSURE FEE ■ $53.00 per hour (3 hours minimum per TANK) 0 TANK(s) x 5159 DO f 159.00 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one time permit, for review/Inspections) TANK 1 D. 0(a) <br /> R <br /> E 1EMPORARY CLOSURE FEE ■ $150.00 each TANK 0 TANK(s) X $150 00 ■ S <br /> P PLAN CHECK (Instail Plan Review E Construction Inspections) TANK I D N(a) <br /> L <br /> A S424 00 minlaxm S <br /> N PLAN CHECK FEE - 153 00 per hour (8 hours minlacm per Fec111ty)� <br /> R REPAIR FEE (workplan review t construction Inspections) TANK I D 0(a) <br /> E <br /> P TANK REPAIR FEE ■ 153 00 per hour 0 hours miniaxWFANK) 0 TANK(s) X $159 00 ■ 3 <br /> A <br /> I <br /> R PIP1110 REPAIR FEE ■ SSI.OD per hour (3 hour minlm><ra per tec141ty 5159 00) <br /> UN :CoHSIULIATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> FEE N 153 00/hr FEE ■ S 53 00/hr <br /> /hr <br /> • TOTAL DUE S 1 <br /> OFFICE USE ONLYow mWel <br /> _ 7rft—r <br /> _ <br /> ma '00 <br /> I( 2 <br /> - F <br /> _ /s � U0 3 <br /> Mr �E„,T■,j ",„�W► wM�iwrwi■■■+r■w�■w�wM waw�i►r,w rw iw■,■M ww Mr000M.� man* .�w.»■.i».� wnN wrnw++�w ■ur■w7wwtMw+rw■.i ww w+w ww <br /> MNNNm MwwwrTIMINMwmIMlmll 1arMw+riMawIplMmMawNNMrMMN"WsalMMMNMlNMMMwVxW0NMZWmwWW4rwMMIMmwMMNMwNMIMMMNMNrrNWOMMINawawNMworiRasNMImwMMMNMIw <br /> EN 23 012 (REV 1110/911 It Pace I <br />