COMPLIANCE INFO_1997-2002 - Laserfiche WebLink

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SAN JOAQUIN COU ABLIC HEALTH SERVICES - ENVIRONMENTAL HEALOIVSION UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET S FACILITY SITE NAME FACILITY CONTACT NAME I ARCO AM/PM Mini-MARKET Store Manager T E FACILITY ADDRESS SITE PHONE # with AREA CODE 2470 Grant Line, Road & A CITY Tracy STATCAEI ZIP 95376DE at SITEof NKS P P APPLICANT/BILLING NAME APPLICANT CONTACT NAME L Barghausen Consulting Engineers Stephen Kirk I C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE A 18215 72nd. Ave. S. (;0'6) 251-6222 NSTATE ZIP CODE TYPE of APPLICATION T CITY KENT WA 98032 (Closure, Installation, etc.) TOTAL 1986 1987 1988 1989 1990 ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 A XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX C T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX i V TANK FEE = $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) E # Tanks = 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 F (multiply #rbyL for - A each year applicable) XXXX XXXX XXXX XXXX XXXX ' n- 5 '5(d Dg0101 C I TANK PENALTY FEES ASSESSED I XXXX XXXX XXXX XXXX XXXX $ L5 18.50 1 STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 iUW D407010 T Y # Tanks 7 x $8.00 1988 through 1990 (S56) 1991 through 1996 ($56) 1997 SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX MANENT CLOSURE emova or Authorize -los`irye-in-Place) NK I.D. #(s) O C_OS E FEE = 5 .00/hour (3 hours nimum/TANK # ANK(s) $234. = $ S 7 1 & 2 U TEMPORY CLOSU E (Plan Rev ew & I pections) TANK I.D. #(s) R E TEMPORARY URE FEE = $78.00/hour (3 hours minimum/ ITY) $234.."00,`mini MI. 5 2 P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) L (r�_ A N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum $ R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) E P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ A I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ R PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ I S C1 CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr $ TOTAL DUE 5998.50 FOR OFFICE USE ONLY _........................:::::::::::::::::::::::-::::::::::::::-:::::::.—::::::::::-:::::::::.::...-._:..................:::::::::::::::::::::::-:::::::::::::::_:::: ::::::::::::::::::r::::::......:::::-::::::......::::.:.:....................................::.....-:::::r:::::::: ............ ::::::::::::::-::::::-.... .._................................................. ........................................................................................................................................::::::-::::::::::r::-:r:::::::::�::::::::::....:.....:.:.:.................:::::::%kii.::- _..............................................................................._........-::.....................................................................................---_..........................._................ :.:.........._.....................................................:............_........`"�!�-M��,«M— =:`€ :::r.._........................................................................................._.................._...._.......................... SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED 5 l..................................................... ......................................::.:::::.:::. .:::::::::::::::r::r:::::::::::::::::::. ::::::::::::::::::::::::::r:...................... _..........._.......1.:.... :................................................................................................................:..:......... ::::::::: ::r:::: ::r:::::::::.::: EH 23 032 (REVISED 5-27-97)