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SAN InAOU114 D"TY TMMLIC HEALTH SERVICES - ENViROMMENTAL NEALTN bIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE SIORKSHEET :� <br /> S FACILITY SITE MANE FACILITY CONTACT NAHE <br /> T Teresi Trucking - Todd� Tere'si (209)368-2472 <br /> E FACILITY ADDRESS SIZE PHONE 0 with AREA <br /> 900 1/2 E. Victor Rd. ;t. (�20 ) 368-2472 <br /> CITY STATE ZIP CGDE I ofi'iIANKS <br /> A A at SITE <br /> P -- — <br /> r APPLICANT/BILLING NAHE APPLICANT CON AG MAKE. <br /> L Teresi Trucking 1� Tod+ 7�eresi <br /> C MAILING ADDRESS APPLICANT PH04E N WITH AREA CODE <br /> M 00 1/2 E. Victor Rd. 1{(209)368-2472 <br /> I CITY STALE ZIP CODE TYPE ofi APPLICATION <br /> (Closur,e, Installation, etc.) <br /> j� TOTAL <br /> 1986'' 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 1100.00 <br /> A XXXX = XXXX '' XXXX $ <br /> C — <br /> I FACILITY PENALTY FEES ASSESSED (If Arplicmbte) xxxx XXXX :.j xxxx $ <br /> I <br /> V TANK FEE _ 150.00/1ANK (Prior to January 1,1991) 1170/TANK (After! January 1, 1991) <br /> F. <br /> I Tanks = 1986 1987 1988 1989 1990 1991 1992 19931 1994 1995 1996 <br /> F (multIpty fF y�yfee for <br /> A emch yenr mrpllcnble) xxxx xxxx xxxx s <br /> } TANK PENALTY FEES ASSESSED XXXX XXXX xxxx $ <br /> t <br /> I STATE SURCHARGE - 156.00 each TANK (Due every 5 yemrs) See Cnllfornfa H A 5 Code,`Sectlon 25287 <br /> Y I Tanks x 156.00 1986 through 1990 1991 through 1996 <br /> (Enter mmount and year) <br /> s <br /> C PERHANENT CLOSURE (Removm( or Authorized C(osure-in-Place) TANK I.D. it(s) <br /> U CI.0911RE FEE - $78.DO/hour (3 hours minirmm/TANK) I mix(s) -3 X $234.00 - V02.00 <br /> S —- -- — <br /> U 1EHrORARY CLOSURE (Plan Review 9 Inspectlorls) TANK I.D. A{s) <br /> R <br /> E TEHrORARY CLOSURE FEE = 178.00/hour (3 hours minimum/FACILITY) 1234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review R Construction Inspections) TANK I.D. d(s) <br /> t <br /> A I <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours mirtim.m/FACILITY) _ $624.00 i minilTRiin ! <br /> R REPAIR FEE (Workptnn Revleu X Construction Inspectlons) TANK I-D. !f(s) <br /> E <br />` P TANK LINING REPAIR FEE = 178.00/hour (3 hours minimum/TANK) N TANK(s) h X 9234.00 = ! <br /> k A <br /> 1 TANK RETROTIT REPAIR FEE = 178.00/hour (3 hours min./FACILITY) _ '1234,00 Jlminimum f <br /> R <br /> PIPING REPAIR FEE = 178.00/hour 0 hours minimum/FACILITY) - 5234.00 'jminl" S <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr ! <br /> r <br /> C CONSULTATION FEE a !7(3.00/hr SAMPLING INSPECTION FEE _ $78.00/hr : <br /> MAL DUE ! <br /> E ill�l!IGi; F!li!�i!11EII1iliiTll nil]Iri.!II!!i r:Ilnilnf?EiR!f int 1.lnlltll!!!T1?]!P3!n Illi?;!lnftl[!!i i'ppif?4nfnlnnlll!!Inn!!nllnn!!!!!!!!!!!!ri!!n!!!li!mE3!;F3!;3??i!3 <br /> ARE Rr 1i 11 llmim IIIIInnIRmn rn�3 <br /> I ns:q , �:v n ss q ff 3 I, I r �:r 1 !! e r s m r uliu rpii�w r i r r 1'F11� 1 I. 11 r I <br /> ���:€�,!: :,. rad � :!!., : r ,,,, � ��'����r.. �����>; � <br /> .!I:illi!i!?imlllilllfll111!if!l4lmFl1!iSfif!!431 I r <br /> n!;r!::nnpm:nun;rni!?.r!r if:rrrrr.;.e.pn..rs.;.r.r.r E1 sa•:1:..!IILIu.mn.u.fl.u.l.u.1.:.u..n..:i.r.i.i.n..i.n..n..i.�.3?�.n..n...n..u..:a..n..iSlu...n:...Rr.lq <br /> fn. 1 <br /> ir.1f!!!?nLnl.ls.l{lr.l{l<.!{!d.r.s.nn..n!flr.1tln..iLtln.ln.f.!RIn•rm.n..ll!lryi.H.�.!"!u.I.!ss.i.f:.in,..a.l.Sr.mn..r.rr.mr.r.Frm.!.3.(:.Kr3?n.f.lr.f41a..I+.m.1..m $!:1 1s33�3•;3:.�39;31;!1'� <br /> 11 p ..InpfP�nn <br /> (!�3q <br /> EN 23 032 (REVISED 4.29.94) Page 11 <br /> "s <br />