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SAN JOAQUIN COCA PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALvQIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> ( JOLLY JOE'S BAIT & TACKLE Kenney <br /> r <br /> E FACILITY ADDRESS SITE PHONE N with AREA yODE <br /> 101 W. Charter Way <br /> 1209) 948-6344 <br /> 6 <br /> CITY Stockton , STATE ZIP CODE If of TANKS <br /> A <br /> CA 95201 at SITE 1 <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> CHARTER WAY INVESTMENT CO. RON SHELAN <br /> C MAILING ADDRESS APPLICANT PHONE K WITH AREA CODE <br /> A P. 0. Box 293 (209) 576-7501 <br /> N <br /> I CITY R1 OT1 STATE ZIP CODE TYPE of APPLICATION Removal <br /> P CA 95366 (closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A f <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xX%X %XXX f <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> k Tanks = 1986 1987 1 1988 1 1989 1 1990 1 1991 1992 1993 1994 1995 1996 <br /> F (multiply f by fee for <br /> A each year app(icable) 5 <br /> C <br /> I TANK PENALTY FEES ASSESSED XX%% XXX% I f <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y N Tanks 1 x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> 1986-1990 56.00 1991-1993 56.00 f 112.00 ((3� <br /> o>b <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. M(a) �MOy13 <br /> 0 CLOSURE FEE - 578.00/hour (3 hours minimum/TANK) M TANK(s) 1 X $234.00 f 234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. k(a) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minima f <br /> P INSTALLATION PLAN CHECK (Plan Review & Core truction Inspections) TANK I.D. A(a) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimuNFACILITY) _ $624.00 minimum S <br /> 71 <br /> R REPAIR FEE (Workplan Review & Core truction Inspections) TANK I.D. #(a) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimm/TANK) k TANK(s) _ x 5234.00 = f <br /> A <br /> 1 TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 mini mm f <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours miniauA/FACILITY) = $234.00 minimum f <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> 5 <br /> C CONSULTATION FEE = $78.00/hr I SAMPLING INSPECTION FEE _ $78.00/hr f <br /> TOTAL DUE $ 346.00 <br /> FOR OFFICE USE ONLY <br /> a <br /> e.......................... ........................ .................... ........................ .................................. .............................. .................................... ..........................................Me <br /> �a:,.�arawma�r:. rirxswriw `wirm� �ra`rew�zxuzmw:w`rw.rcxAwna.riswxwAwoir,wwmw�ix.wrwrasra.ia�ieria.isw`.wivrwAisaiwaissiwmro:w <br /> EH 23 032 (REVISED 3-1-931 Pane 11 <br />