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r SAN JOAoOIN (.— IT PUBLIC HEALTH SERVICES - ENVIRONMENTAL .,r,TH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY CONTACT NAME <br /> SiFACILITY SITE NAME A.R. ROY FO4'iLEP. <br /> I FOWLER'S <br /> T SITE PHONE # with AREA CODE <br /> 'E FACILITY ADDRESS 405 N. EDISON STREET (209) 94(0 4035 <br /> & ;TATEh�P2 CORE x of TANKS <br /> CITY STOCKTON A 7 US at SITE 7WO (2) <br /> A <br /> P APPLICANT CONTACT NAME <br /> P APPLIC.ANTILB[ALLSINGDIR�ECTLY ABOVE <br /> L VEE <br /> I APPLICANT PRONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CITY (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 11987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to Jenuery 1, 1991) = 5100.00 XXXX XXXX xxxx XXXX XXXX S XXXXXXXX <br /> A <br /> C xxxx xxxx xxxx XXXX XXXX s xxxxxxxx <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> T5170/TANK (After January 1, 1991) <br /> V TANK FEE = 550.00/TANK (Prior to January 7,7991) <br /> E % Tanks 1988 1989 1990 1991 1992 1993 7994 1995 1996 17997 1998 <br /> = <br /> F (multiply # by fee for I f <br /> A each year applicable) xxxx xxxx xxxx XXXx xxxx <br /> C S <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX xxxx (xxxx <br /> L S <br /> I STATE SURCHARGE FOR NEN FACILITIES ONLY-518.50 <br /> T <br /> Y # Tanks_ x 58.00 1988 through 1993 (E56) 7993 through 1997 (556) 1998 <br /> SURCHARGE FOR 1998 xxxxxxxxxxxxxxxxxxxxxxxxxxx XX%XXXXXXXXXXXXXXXXXX%X PS : <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) I N TANK(s)rJ0 % 5234.00 s .00 <br /> S TANK I.D. #(S) <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> R 15 <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minioun/FACILITY) 5234.00 minimm <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A5 <br /> N PLAN CHECK FEE = S78.001hour IS hours minimum/FACILITY) = S624.00 minimm <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br /> E5234 + S <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X .00 <br /> = <br /> Ai <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum <br /> R - 5234.00 minimin s <br /> PIPING REPAIR FEE = 578.00/hour (3 hairs minimum/FACILITY)LITY) <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr ( S <br /> I I � <br /> SI ' S <br /> ClCONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = S78.00/hr <br /> TOTAL DUE S 408.00 <br /> FOR OFFICE USE ONLY _ ......, _ ....___ — <br /> .M=F;uce:_y:.�:_sand�:::__...waay�:n�-�c;m�...._ _..._ _. :�:__.z:=�c:�_ <br /> SWEEPS # COMPUTER # LOC CODE I DIST CODE I AMOUNT RECEIVED LHECK #/C)15N RECEIVED dT GATE RECEIVED <br /> LJ <br /> 5 — <br /> r <br /> Fa 7; nl;l tRFVISF.D 1-12-98) <br />