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SAN JOA(IU1*tCUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAIIEALTH DIVSI0N <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I Carl ' s Jr . Distribution Cente Dave Cultrera <br /> T SITE PHONE # with AREA CODE <br /> E FACILITY ADDRESS S 209)823-9251 <br /> 800 Mellon t . � <br /> E STATE ZIP CODE # of TANKS <br /> CITY at SITE 2 <br /> A Manteca CA 95337 <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME Bob Singh <br /> L CKE Restaurants <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A P.O. Box 4349 (417 )490-3603 <br /> N STATE ZIP CODE I TYPE of APPLICATION <br /> T CITY Anaheim, CA 92803-434(3iosure, Installation, etc.) Removal <br /> TOTAL <br /> 1986 1987 1988 1989 7990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1997) = $100.00 XXXX XXXX XXXX XXXX XXXX E XXXXXXXX <br /> A <br /> CXXXX XXXX XXXX XXXX XXXX E XXXXXXXX <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I5770/TANK (After January 1, 1991) <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) <br /> E <br /> 0 Tanks = 7987 1988 7989 1990 1991 1992 1993 7994 1995 1996 1997 <br /> F (multiply p—by fee for S <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 <br /> I STATE SURCHARGE <br /> 7 <br /> Y # Tanks_ X $8.00 1988 through 1990 ($56) 1991 through 1996 (S56) 1997 <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = minimum/TANK) <br /> (3 hours minim /TANK) # TANK(s) 2 X $234.00 = s468 .00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review d Inspections) TANK I.D. #(s) <br /> R S <br /> E TEMPORARY CLOSURE FEE = 578.001hour (3 hours minimus/FACILITY) $234.00 minimus <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A E <br /> N PLAN CHECK FEE - $78.00/hour (8 hours minimm/FACILITY) = $624.00 minimum <br /> R REPAIR FEE (Workplan Review 6 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X !234.00 = E <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minims S <br /> R uS <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minims <br /> M TRANSFER FEE 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr $ <br /> I <br /> S E <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = $78.00/hr <br /> 7 wL I IS TOTALUE $468 .00 <br /> D <br /> S <br /> FOR OFFICE USE ONLY .m :: : L/. :::: :::..:: :: lI.�.:e� .(, ,A:!! 'f::::__:. :::...: <br /> n!!1 <br /> minnclmmm nunnnnnnn!usnn!!!nna!nn!mm.Immm�s.!me;l:...,!..:.....n :: .. �In!nnnnnmsnnnunnnnnnnnerain!!au::::r:nm!aumimiiirniam:r!r,.!!nni'' linnnnannllm;;nn;mnnnru:nnaiminmm�mm�nnn!rn::nio <br /> iii1110WE ENIWIIIilllliillliil!m!I!Iillmlllllm!II11!I#I1111111111Gwlla:Llllllm!lHiilrirAll..IIIIInLIIIIIW:ImI!riiIII AM IIII.iiiiiiL illi <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMIXINT RECEIVED CHECK #/CASH RECEIVE BY DAZE RECEIVED �) <br /> IN ri <br /> s <br /> S <br /> Nlnninnn!nnmlll nmm!mnmrlnnmulrI lnlu::::luimslmenna!!i:!i!nIIaIn.rII!nmWnlalii!ii!l!l!ir�! ll.l..li..i.a.l..11.-n.t:i. <br /> i!!r!!i!lrl:l:lrileil:!aill:ull.=!.11iellnllmiliililIlnlinll:i!lc!ii!eIl!iuilnll!ii!nIlilulimrrrali.=l.l:!!lrinilir:l!lnln!ilInllii:l!ii!i.nn.2n !:i <br /> Nil! milt.. <br /> s!i! <br /> i lIsnlens11irsil <br /> A!i ` lIiillll!II! Iilllllllllll lllllll!r!1II11IIIIIlllIHll111MR1111!ii: <br /> EN 23 032 (REVISED 5-27-97) <br />