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'AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES y J <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UND�GROUND STORAGE TANK PROGRAM - EEE WORKSHEET NWOr <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F Don Pelin CPM <br /> A Boettcher Western Properties 111 , Ltd. gI <br /> C SITE PHONE M with AREA CODE NIA <br /> 1 FACILITY ADDRESS 4555 N. Pershing Ave. <br /> L <br /> 1 STATE ZIP CODE of TANKS <br /> I CITY Ca. 95207 at SITE 3 <br /> + Stockton, <br /> A APPL ICANI/BILLING NAME APPLICANT CONTACT NAME <br /> P Boettcher Western Properties 111 , Ltd. Don Peling, CPM <br /> t APPLICANT PHON@ ,! Ar <br /> WITH S�IlR CODE <br /> I MAILING ADDRESS 850 W. March Ln. (20914 ! <br /> C <br /> A STATE 21P CODE TYPE of APPLICATION - <br /> N city Ca. 95207 CLOSURE, INSTALLATION, ete.Removal <br /> I Stockton, <br /> TOTAL <br /> A - i986 1987 1988 1989 1990 <br /> C <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) a $100.00 5 <br /> I <br /> V - 5170/LANK (after January 1, 1991) <br /> E TANK FEE • $50.00/TANK (prior to January 1,1991) <br /> E I Tanks 1986 1987 1988 1989 1990 1991 1992 1991 1994 1995 1996 <br /> A (mdtlply I-Gy fee for f <br /> O each year smile ebl e) <br /> 1 <br /> t STATE SURCHARGE + 056.00 each TANK (Due every S yearn) See California H t S Code, section 25287 <br /> 1 1986 through 1990 1991 through 1996 <br /> 1 R Tanks K $56.00 <br /> y (enter amoant and year) 5 <br /> PERMANENT CLOSURE (Removal or Authorized Cloaure-in-place) TTRNK .D. /(a)777777T= <br /> L CLOSl1RE FEE 553.00 per hour (3 hours minlnasn per TANK) TANK(s)�_ X !159.00 $ <br /> S <br /> U TEMPORARY CLOSURE (A om-tlme permit, for review/Inspections) TANK I.D. I(s) <br /> A <br /> E TEMPORARY CLOSURE FEE • !150.00 each LANK R TANK(s) _ X <br /> P PLAN CHECK (Install. Plan Review 6 Construction Inspections) TANK I.D. N(s) <br /> L <br /> Af <br /> N PLAN CHECK FEE - 553.Oo per hour (8 hours minlaua per facility) 5424.00 mini nam <br /> R REPAIR FEE (workplan review S constructlOn inspections) TANK I.D. A(S) <br /> E <br /> P TANK REPAIR FEE + 153.00 per hour (3 hours minln"WTANK) S TANK(s) _ X $159.00 • 5 <br /> A <br /> I • !159.00) 5 <br /> R plPING REPAIR FEE _ $53.00 per hour (3 hour mini" per facility <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> SFEE = f 53.00/hr -� <br /> C FEE • 153.00/hr FEE = 553.00/hr <br /> TOTAL DILE ! <br /> OFFICE USE <br /> W9O9NLY <br /> .M.Wr. 4•MM....DTed�" W ................. <br /> .........R...IlY.A.Y.VJ�.^......+... <br /> �.......... <br /> ......I.T`...Af.�S...{a1..1.N._r».ow..at...f�....l.y...t..V..»af.�.F..rM_..•.=.M»»�... 'y_a�",y,"yT' <br /> aMMa <br /> rrarrar:r:»ra.c:+ _.� <br /> rrrwrra"<r'irw`w5�inwwrwwwwrwrwnww wrwwr+Rrl <br /> MMYMMMMMMMM MMa1MM MFMMMMMM=MMMa M111MM=MMMMMMaWMMMaY1w MMM=a=IMMYIrMM1Yr1Y IMa1MMaMr" MlMaY1+MMMM MMMM <br /> EA 23 032 (01y 1/10/911 it Pane 1 1 <br />