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SAN UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET N FACILITY NAME FACILITY CONTACT NAME silveria property mr jack bozzano 209 467-8320 FACILITY ADDRESS SITE PHONE#WITH AREA CODE 1933 hiawatha avenue 209 467-8320 CITY STATE ZIP CODE #OF TANKS AT SITE Stockton ca CA 95205 one APPLICANT BILLING NAME APPLICANT CONTACT NAME quality packing shipping ac k bozzano 209 467-8320 APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE po box 5009 209 467-8320 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Stockton ca 95205 )MXure Installation Repair Retrofit ACTIVE FACILITY 1996- 1999 2000 2001 $500 FEE INCLUDES FACILITY FEE+ 1 TANK (5170)X(N tanks)X(N of years applicable) $ $125 PER TANK AFTER FIRST TANK -- $ TANK PENALTY ASSESSED $ TANK SURCHARGE=$8/TANK ---- $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place) $ TANK ID# s CLOSUREFEE=$261 /TANK #TANKS X$261 = TEMPORARYCLOSURE (Plan Review and Inspections) $ TANK ID#(s): TEMPORARY CLOSURE FEE=$261 /FACILITY INSTALLATION PLAN CHECK (Plan Check and Construction Inspections) PLAN CHECK FEE_$696 I FACILITY $ TANK ID#(s): 00 S REPAIR PLAN CHECK TANK ID#(s): TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = TANK RETROFIT REPAIR FEE =$261 /FACILITY $ PIPING REPAIR FEE _$261 /FACILITY MISCELLANEOUS TRANSFER FEE _ $20 CONSULTATION FEE = $87/HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $87/HOUR $ SAMPLING INSPECTION FEE = $87/HOUR ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST N FACILITY)n AMOUNT RECEIVED CHECK# RECEIVEU BY _ DATE RECEIVED SR EH 23 032(REVISED 2E-01)