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SSAN JOAOUIN COUNTY PUBLIC HEALTH SERVICE. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> n <br /> C Ga�E F e <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L 1(005 5o� t ��- ddRP�flo zo9- -Z4;9d 5/o-Z 6-8 c� <br /> I <br /> 1 CITY STATE ZIP CODE # of TANKS <br /> Y STOC�KTON C,A 195206 at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> F, <br /> R013eft� tt• LrEG ASsnUATeS MARK 1-11COF-e <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> G 1 37 r4ORTN MC'00VA eLL. FSLva• C�o`1 ) -16pGj-- i cnco o.. <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION Fr-MOVAcL-- <br /> T 6A q4-q'--5 - I <br /> CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <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 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) $ <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> 1 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> $ <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s)_ X $159.00 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 5150.00 each TANK # TANK(s) X $150.00 = S <br /> PPLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> $ <br /> minimum PLAN CHECK FEE - $53.00 per hour (8 hours minimper Facility) = $424.00 minimum <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = $ <br /> A <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility = $159.00) $ <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $53.00/hr S <br /> 1 <br /> S <br /> C CONSULTATION FEE _ $53.00/hr SAMPLING INSPECTION FEE = $53.00/hr S <br /> V TOTAL DUE $ <br /> OFFICE USE ONLY v <br /> ............................................................................................. <br /> ..................................................................... <br /> ............................................. <br /> Her erne Heave Ha Hoes.Har�««o.H zeo Heees zee woero Hee eeeeee zer Heeee Hao woo zooee zee zero.za zoeee zes ease Heeeo za Hroro za zee»sea zeeeeHa za Heeee Hee Heeoe za eHere zee Hos zeeee zee ioeeei ioei ieiiei i:e+ieeiee iee>ieee".'«*»r.► <br /> H <br /> C1L��Q $ <br /> fn DSD C A" S y <br /> r"'ne a x'�x zm c s"rmx xODa z o ==!I�.•e z=="52w t w lv= *W *W ANN r""""�M ser y <br /> EH 23 032 (REV 4/8/91) ft Pace 11 x �+//� <br />