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10SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISICN <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A Port of Stockton <br /> c Akio ire Biro <br /> I FACILITY ADDRESS 2201 Washington St. SITE PHONE # with AREA CODE <br /> L (209) 946-0246 <br /> I <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y Stockton Ca. 95201 at SITE 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> A <br /> P Same as above Same as above <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CCD_ TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. Removal <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> V <br /> I X :E=X X X 4 600.00 <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1 1991 1 1992 1 1993 1 1994 1 1995 1 1996 <br /> A (multiply # by fee for <br /> C each year applicable) X X X X X X $ 670.00 <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_j_ x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> X S <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)1_ x $159.00 = $ 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 FTEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) x $150.00 = $ <br /> P PLAN CHECK (Install. Plan Review & 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 i <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 miniauWTANK) # TANK(s) x $159.00 = $ <br /> A <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimun per facility = $159.00) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE _ $53.00/hr FEE _ $53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE $ 1541 .00 <br /> OFFICE USE ONLY <br /> »»�»zea,.zv+zawowa.wwa�znzae zaw z.�zawza�aweos za wow.was z»woaoe zae zaoaa was wwwww was waeae was»e000 zap wow wa www ww aaoa zaw.xo.zww cow zoow»»xo.z.wa ww zawa z..z.aaa�..zaa..zae�..wwe«zw w <br /> ........................ ........................ .................... ........................ s... . .1:y.�. ...... ..�1.2 .. >1. .........: ........... .. .-.` ...f.,.....,.... <br /> w»aw ww»wee»aw�zo�»ww•zMwe►eww�zwznu w»wweraw wwxw»w»wwwza►zwrww waww..w..www w.•waw w»waw w» w»awa.«..aw wawzer wwaeawaw waw w»za..a we.zwo►weo zowrw»zee zw»w»� <br /> EH 23 032 fREV 1/10/91) ft Paoe 11 <br />