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tl <br /> SAN J04WIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUID STORAGE TANK PROGRAM - FEE WORKSHEET <br /> TEN E FACILITY CONTACT NAME <br /> and Plaza Henery Barkett <br /> ITT ADDRESS SITE PHONE X with AREA CODE <br /> 678 North Wilson WAY 209 951 5787 <br /> CITY STATE ZIP CODE X of TANKS <br /> A Stockton Ica 95205 at SITE one <br /> v <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L Henery Barkett <br /> I <br /> C NAILING ADDRESS APPLICANT PHONE X WITH AREA CODE <br /> A PO Box 4146 <br /> M <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> Stockton Ca 95205 (CKxWKe, Installation, etc.) <br /> TOTAL <br /> 1986 11987 11988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A %XXX XXX% XXXx I XXXX %XXX ' S xxxxxxxX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I xxxx xxxx I xxxx xxxx xxxx f xxx%XXX% <br /> 1 L <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) T 1-7D ��� <br /> E <br /> X Tanks = 1988 1989 11990 1991 11992 11993 11994 11995 11996 11997 1998 <br /> F (multiply X by fee for <br /> A each year applicable) %%X% %XXX I %XxX x%XX Ixxxx I 11� 170I ('O 11� � �70 /OD — <br /> C <br /> ! TANK PENALTY FEES ASSESSED I XXXX XXXX I XXXX I xxxx Ixxxx I I I-ID 11,7o 11-10 I (gyp 1110 S <br /> L <br /> 1 STATE SURCHARGE FOR NEW FACILITIES ONLY=S':B.iB--- $10 . 00 s 10 . 00 1 <br /> T <br /> Y X Tanks 1 X 58.00 I 1988 through 1993 (556) � 1993 through 1997 (556) 1998 � <br /> SURCHARGE FOR 1998 xxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx I s 8 . 00 I <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in•Place) I TANK I.D. X(s) <br /> Ll <br /> SI CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I X TANK(s)� X 5234.00 = + 5 234 0 0 <br /> U TEMPORARY CLOSURE (Plan Review 4 Inspections) I TANK I.D. X(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimum/FACILITY) I 5234.00 minimus I S <br /> P INSTALLATION PLAN CHECK (Plan Review 6 Construction Inspections)I TANK I.D. X(s) <br /> Li <br /> Al <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimm/FACILITY) = $624.00 minimum + s <br /> R REPAIR FEE (Workplan Review d Construction Inspections) I YANK I.D. X(s) { <br /> F <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) X TANK(s) % 5234.00 = f <br /> A -- <br /> I ' TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) = S234,00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimm/FACILITY) = S234.00 minimum S <br /> B <br /> N TRANSFER fEE • S20.00 I UNAUTHORIZED RELEASE '.VALUATION = 578.00/hr I I S <br /> I <br /> 5 <br /> C CONSULTATION FEE = 578,00/hr I I SAMPLING INSPECTION f"cE = 578.00/hr I I 5 <br /> TOTAL DUE S 252. 00 <br /> C <br /> FOR OFFICE USE ONLY <br /> SWEEPS X COMPUTER Y LOC CODE DIST CODE AMOUNT RECEIVED I CHECK 9/CASH RECEIVED BY DATE RECEIVED <br /> S i <br /> ..- <br /> rw 7'4 nt7 fRFVISFD 1.12-98) <br />