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SAN JOA0UtN COUNTY PUBLIC HEALTH SERVICES <br /> 4 <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> . FACILITY SITE NAME FACILITY CONTACT NAME <br /> r <br /> A Knox ' s Texaco Food Mart Keith A . Tallia 209-754-1808 <br /> C <br /> I FAC`LITY ADDRESS SITE PHONE # with AREA CODE <br /> L 633 E . Victor Road New (none) <br /> t <br /> T CITY STATE jZtP CODE # of TANKS <br /> Y Lodi ICA 95244 at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P OIL EQUIPMENT SERVICE Keith A . Tallia <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C PO Box 950 209-754-1808 <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T San Andreas CA 95249 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 /> I f <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 1992 1993 1994 1995 - 1996 <br /> A (multiply # by fee for <br /> C each year applicable) f <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> t <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> f <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 $459:09 150 .00 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> RE r TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = f <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 minimm S <br /> R REPAIR FEE (workptan review & construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimunt/TANK) # TANK(s) X $159.00 = f <br /> A <br /> I <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 /> S <br /> C FEE = $53.00/hr FEE = $53.00/hr FEE = f 53.00/hr <br /> TOTAL DUE $ 150 .00 <br /> OFFICE USE ONLY <br /> wa moo moao mw ma maem ma ma m000a ma moms moo meow moo moeoo mo►mos moos»a.»Dassova.xama xa ma taoma xo►xeo»mos was roma�wae m»»as zea»xa s xa.mae.w»xo.aoawe xa wewo�a.xaw Mo►i�a»ee xa neo.xo.»» <br /> ms`s s�"" iXweWelijord"M X1 <br /> l` 'EDU Qtr $ <br /> iiweuwaii000»idamwaim►i�► mamaeiiiaoie»ii�uaa.iweuao»ii»iu►ieii»foamei»ie»uwiewe:fmwiwe»ius»a»iMiiwe»i »es; esm» A <br /> EN 23 032 (REV 1/10/911 ft Pace 11 <br />