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•SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY SITE NAME FACILITY CONTACT NAME <br /> A Frederick R. Mayers Dick Mayers <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L 126 S. Main St. N/A <br /> I <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y Lodi Ca. 95240 at SITE 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L Frederick R. Mayers Same <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A 23575 N. Elliott Rd. 8- <br /> 6495 <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T Acam o Ca. 95220 CLOSURE, INSTALLATION, etc. Removal <br /> A TOTAL <br /> C 1986 1987 19881989 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 1 1992 1993 1994 1995 1996 <br /> A (multiply # -by fee for <br /> C each year applicable) E <br /> I <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 amunt and year) <br /> s <br /> PETEMPORARY <br /> NENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> RE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) 1 X $159.00 $159.00 <br /> RARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 S <br /> P PLAN CHECK tImES53.00 <br /> lan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE per hour (8 hours mini mm per Facility) _ $424.00 minimum $ <br /> R REPAIR FEE (workplan review & constructlon inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimtWTANK) # TANK(s) X $159.00 $ <br /> A - <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour mini mm per facility = $159.00) $ <br /> H CONSUL TAiIOUS 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 $1 00 <br /> OFFICE USE ONLY <br /> . . ....... ........... . .................................... . ............ ....._ ....... ........ <br /> xei vee s:ee..ee uioes=e..eeii fee.iee..xe.wee..eer xe.weee.wee miez» anese:ieeeiw4swa.weee:.'eer:eeei»e.. """"ieei=Ge:iG..e..ee:in.game.=eYzeee:ue::a:»e'ei:we:.seu:«zeeei <br /> S I�Er`S ' ( ' ° C ) `s "L ` G '�IC1 S "` 'L �°awa' rffm .'" <br /> w.a.wee.....w.ee.w.w.ae.=e..aw.r.ar aw=.e.=»res.o.wroewa.».xe.xrimes ix.r.eeew whuw»e..ee,..e..ee»....s=......reee. ...re....x=w.e.eiAo.««iwe.eee:::ir Aeeri:«iee�i <br /> ax ra u wms arc aa�mx srox my w mos se eY pxa a xex:mays xrr zw ax as Jnr m s mer r Mr xa a r:ua'mr:arw a o�maw,:uw:e as r w xaw xw fix:rae s w zmr w uaw w xw r xsx m w:�xsr:Y r as wr e e rs w xK f w xr w <br /> EH 23 032 (REV 1/10/911 It Paae 11 <br />