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SAN J011tX)IN CPUBLIC HEALTH SERVICES - ENVIRONMENTAL HEAVSION <br /> UNLIWOUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY CONTACT NAME <br /> S FACILITY SITE NAME <br /> I <br /> T SITE PHONE # With AREA CODE <br /> 'E FACILITY ADDRESS <br /> 2191 NavyDr. Stoc 209-943-2011 <br /> 3 STATE ZIP CODE # of TANKS <br /> CITY Ca . 95201 at SITE 8 <br /> A Stockton <br /> P APPLICANT CONTACT NAME <br /> LA <br /> ICANT/BILLING NAME <br /> Dan Samuel <br /> APPLICANT PHONE # WITH AREA CODE <br /> ING ADDRESS 209-931-5513 <br /> P.O. Box 737 STATE ZIP CWE C a. 95252 <br /> (Closure, Installation, etc.) <br /> Valley Springs <br /> TOTAL <br /> 1986 1987 11988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 XXXX XXXX I XXXX I XXXX XXXX S XXXXXXXX <br /> A <br /> LXXXX XXXX XXXX XXXX XXXX 5 XX%X%X%X <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> IS170/TANK (After January 1, 1991) <br /> V TANK FEE SSO.00/TANK (Prior to January 1,1991) <br /> E <br /> # Tanks = _ 1988 7989 1990 1991 1992 1993 1994 1995 1996 1997 1998 <br /> F (multiply # by fee for I I I S <br /> A each year applicable) XXXX XXXX I %XXX I %%XX XXXX <br /> C I I I S <br /> I TANK PENALTY FEES ASSESSED I XXXX XXXX XXXX %XXX (XXXX <br /> L S <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=S18.50 <br /> T 7988 through 1993 (S56) 1993 through 1997 (S56) 1998 <br /> Y # Tanks_ X $8.00 <br /> SURCHARGE FOR 1998 <br /> XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> L # TANK(s) g_ X 5234.00 = S 1872 . 0 <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br /> STANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) <br /> R S <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review 3 Construction Inspections)I TANK I.D. #(s) <br /> L <br /> A = S624.00 minimum S <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> JPTANK LINING REPAIR FEE = 878.00/hour (3 hours minimum/TANK) # TANK(s) _ X 5234.00 = S <br /> ANK RETROFIT REPAIR FEE = 878.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> IPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br /> S <br /> I <br /> S = S78.00/hr I S <br /> C CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION FEE <br /> TOTAL DUE S <br /> USE ONLY .... ---_=-.__—.�,._........ ............... <br /> FOR OFFI ... __—_....._.._ , _.._..—__:�- - ME <br /> wIMM <br /> .:. <br /> 1.11 <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK /CA <br /> RECEIVED BY DATE RECEIVED <br /> ii <br /> S <br /> I <br /> M.M. <br /> —.-... ._—_.--T—.—.......__...____..............—.—.__....._—_.......___................._ __................i.!.-....... <br /> EH 23 032 (REVISED 1-12-98) <br />