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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGRCUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> _r <br /> yFACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A Port of Stockton Aldo Fre gairo <br /> C SITE PHONE $ with AREA CODE <br /> I FACILITY ADDRESS 2201 Washington St. (209) 946-0246 <br /> 4 <br /> I =Ca. <br /> '95:201; <br /> # of TANKS <br /> T CITY StOCktoll <br /> at SITEA APPLICANT/BILLING NAME LICANT CONTACT NAME <br /> P <br /> P Salve as above Same as above <br /> L APPLICANT PHONE # WITH AREA CODE <br /> I WAILING ADDRESS <br /> C <br /> A STATE ZIP CODE ITYPE of APPLICATION <br /> NCITY CLOSURE, INSTALLATION, etc, <br /> T Removal <br /> TOTAL <br /> A 1986 1987 1988 1989 1990 <br /> C <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 X X X X1:4 $ � <br /> 1 <br /> V <br /> E TANK FEE 350,00/TANK (prior to January 1,1991) $170/TANK (after January 1, }qg}) <br /> F 0 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 }995 1496 Z- : <br /> A (msu(tiply # by fee for X X X X X X <br /> C each year applicabte) <br /> 1 <br /> L STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See Cakifornia H & S Code, Section 25287 <br /> 11991 throw 1996 <br /> T # Tanks__ x $56.00 1986 through 1990 9h <br /> y (enter amount and year) $ <br /> X <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)_L_ X 5159.00 = $ 159.00 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R # TANK(s) X $150.00 = $ <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK <br /> P PLAN CHECK (Install. Plan Reviews & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A $ <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per 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 miniaxWTANK) # TANK(s) X $159.00 = $ <br /> A <br /> I3 <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility = $159.00) <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> 5 <br /> C FEE _ $53,00/hr FEE _ $53.00/hr FEE S 53.04/hr <br /> TOTAL DUE $ 1541 .00 <br /> OFFICE USE ONLY <br /> .......................................................... <br /> �...�+�...r..»»..,»».�a»...v.,,,.,,.,..r.»»»».,..+.�.»»»o...+.».a............�..�....V"�'�l�i� <br /> ,^�wwiiii�»«•»iiii iliiir iiiiww»�s»r aM►s�rr "�•wl1K:WPrYW ApiAMMPAM AMM XIgX AMr AWMPAWI{AXpW ACIP AYMAR�fI'AYP XiRMAMrPi AMIE ApM AMPK AiMf AM11M XPi AMM AWWNApMAMP MMANXA <br /> Xif AMP XS"AMP ow AMP X"AWAWP ow im MW AXP so*AAAI X." <br /> EH 23 032 (REV 1/10/91) ft Paae 11 <br />