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ON JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION T <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE LCRKSHEET <br /> FACILITY SL TE NAME FACILITY CONTACT NAME <br /> . F <br /> A Mildred De Vi.ncenzi Bob Hesselt;ine <br /> C <br /> I FACILITY ADDRESS SITE PHONE 0 with AREA CODE <br /> L 21167 N. Trethewa Rd. <br /> I <br /> T CITY STATE ZIP CODE 0 of TANKS <br /> T Acampo, Ca. 95220 at SITE 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAVE <br /> P <br /> P Mildred De Vincenzi same <br /> t <br /> I MAILING ADDRESS 12267 E. Eight Mile Rd. APPLICANT PHONE M WITH AREA CODE <br /> C (209) 931-3486 <br /> A <br /> Y CITY STAfE ZIP CODE TYPE of APPLICATION <br /> T SL CLOSURE, INSTALLATION, etc Removal <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> F 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) 5170/YANK (after January 1, 1991) <br /> F 0 Tanks ■ 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply by tea for <br /> C each year applicable) , S <br /> I <br /> L STATE SURCHARGE _ $56 00 each TANK (Due every 5 years) See California H S Code, Section 25287 <br /> I <br /> T 0 To <br /> x $56 00 1986 through 1990 1991 through 1996 <br /> Y (eater amount and year) <br /> $ <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK 1 0 9(s) 464 <br /> L CLOSURE FEE _ 953.00 per hour (3 hours minimum per TANK) N TAUIK(s) 1 X $159.00 f 159,00 <br /> 0 <br /> 5 <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK 1 0. 0(s) <br /> R <br /> E TEmPCRARY CLOSURE FEE = $150 00 each TANK 0 TANK(s) X $150.00 - f <br /> P PLAY CHECK (Ira tall Pian Review & Construction Inspections) TANK 1 0. $(s) <br /> L <br /> A <br /> NEEPLAN CHECK F $53 00 per hour (8 hours minf" per Facility) - $424 00 minimum $ <br /> R REPAIR FEE (workplan review Z construction Inspections) TANK I D. #(s) <br /> E <br /> P TANK REPAIR FEE - $53 00 per hour (3 hours minimrn/TANK) $ TANK(s) X $159 00 = S <br /> A <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility = 3159 00) f <br /> Y CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE - $53.00/hr FEE = $53 00/hr FEE = $ 53 00/hr <br /> TOTAL DUE $159 <br /> OFFICE USE ONLY <br /> iww..w___M!► +�wair�.nw»1�t�..rw:ww.7ra�1w�,�.►tiwtirwuy►err..�w�.rw.insaMwsiw�w .��/►�wr�..�tru�wpww1..�.rr.�sw�rrw,wwitw�►u.rww��►�w�wrMrr <br /> �i IUS: DISI 6[z1t /LASH N�IE �wNws rt�M�� amfMwrww R <br /> �89W <br /> isi■�r,ww�i�M lliwi W�IOMMrM fM fnw� ww�IY►li■wwM ww�w.►Hr»ay�►>�w.►1Ww..r4]�w..`w�A.�lIM1M►wl..��w OrAW" WNWn>•��Y.N►MM <br /> lM1lM11K AIM AMAr ArrAAAArAW � � mom AOMMMr�MMb��AMM<l1A)A��Air mYAMAIM�MiAM AMAM AAMAI�AMrlla ArAA;AOM AMMArA ArOOAAOM WNW OM<AMOM�llllK�����AMM IMAM <br /> EH 23 032 (REV 1/10/911 ft Pace 1 <br />