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A', <br />SAN JOAQUINPUBLIC HEALTH SERVICES - ENVIRONMENTAL H DIVSION <br />STORAGE TANK PROGRAM - FEE WORKSHE <br />S <br />'FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />I <br />DDRW—MFW—SHARPS FACILITY <br />MARLENE JONES <br />T <br />EFACILITY <br />ADDRESS <br />SITE PHONE # with AREA CODE <br />S <br />BLDG S-41 <br />209 982-2422 <br />b <br />CITY <br />STATE <br />ZIP CODE # of TANKS <br />A <br />LATHROP ICA <br />95331-510 at SITE 7 <br />P <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />CRISP PETROLEUM ENVIRONMENTAL <br />LEONARD E. CRISP <br />I <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE E WITH AREA CODE <br />A <br />P.O. BOX 30487 <br />209 931-1828 <br />1994 1995 1996 <br />F <br />A <br />(muttipty x by fee for <br />each year applicable) <br />H <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />$ <br />STOCKTON <br />ICA <br />95213 <br />(Closure, Instattation, etc -)UPGRADE <br />I <br />TOTAL <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Ptace) <br />TANK t.0. #(s) <br />1986 1487 1988 <br />1989 <br />1990 <br />A <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) a 5100.00 <br /># TANK(s) X $234.00 a <br />S <br />S <br />xxxx XXXX <br />S <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & tnspections) <br />TANK I.D. #(s) <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicab(e) <br />xxxx XXXX <br />$234.00 minimum <br />S <br />g <br />V <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) S170/TANK (After January i, 1441) <br />E <br />0 Tanks = <br />1986 <br />1987 1988 1989 1990 1991 <br />1992 <br />f 1993 <br />1994 1995 1996 <br />F <br />A <br />(muttipty x by fee for <br />each year applicable) <br />xxxx <br />xxxx <br />$ <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />xxxx <br />xxxx <br />= <br />L <br />I <br />STATE SURCHARGE = 956.00 each TANK (Due every 5 years) See California d & S Code, Section 25287 <br />T <br />Y <br /># Tanks x 556.00 <br />1988 through 1990 <br />1991 through 1996 <br />(Enter mumunt and year) <br />S <br />C <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Ptace) <br />TANK t.0. #(s) <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = <br />S <br />L <br />0 <br />CLOSURE FEE a 278.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 a <br />S <br />S <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & tnspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE a 578.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />S <br />P INSTALLATION PLAN CHECK (Pian Review & Construction Inspections) TANK I.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE s 578.00/hour (8 hours minimum/FACtLiTY) _ $624.00 minimum S <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE a 578.00/hour (3 hours min./FACILITY) = S234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE a 578.00/hour (3 hours minimum/FACILITY) a $234.00 minimum <br />i <br />M TRANSFER FEE a 520.00 ( UNAUTHORIZED RELEASE EVALUATION a 578.00/hr <br />I � <br />S <br />C CONSULTATION FEE a 578.00/hr SAMPLING INSPECTION FEE a 578.00/hr <br />FOR OFFICE USE ONLY <br />SWEEPS At COMPUTER # I LOC CODE I DIST CODE ' AMOUNT RECEIVED ( CHECK #/CASH <br />f <br />$ <br />TOTAL DUE S <br />RECEIVED SY I DATE RECEIVED <br />EN 23 032 (REVISED 10-28-93) 3 .- <br />