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SAN JOAQUIN COLI LIC HEALTH SERVICES - ENVIRONMENTAL HEALOVSIOM <br />UNDE STORAGE TANK PROGRAM - FEE WORKSHEET <br />'SI <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />I <br />DDRW—MFW—SHARPE FACILITY <br />MARLENE JONES <br />T <br />CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) <br />1986 I <br />E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />3 <br />BLDG 5-41 <br />209 982-2422 <br />& <br />R <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />ALATHROP <br />ICA <br />95331-510 <br />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 />Xxxx <br />I I <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />P.O. BOX 30487 <br />209 931-1828 <br />N <br />I <br />V <br />TANK FEE = 350.00/TANK (Prior to January 1,1991) <br />5170/TANK <br />T <br />CITY <br />STATE <br />ZIP CODE I <br />TYPE of APPLICATION <br />STOCKTON <br />ICA <br />95213 <br />(CLosure, Installation, etc -)UPGRADE <br />C <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Ptace) <br />I TANK I.D. #(s) <br />TOTAL <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = <br />L <br />0 <br />CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) <br />1986 I <br />1987 I 1988 <br />1989 ( 1990 <br />TANK RETROFIT REPAIR FEE = 378.00/hour (3 hours min./FACILITY) = 3234.00 minimum <br />3 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />S <br />R <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />A <br />R <br />EI <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />XXXX I <br />XXXX <br />S <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX I <br />Xxxx <br />I I <br />$ <br />I <br />V <br />TANK FEE = 350.00/TANK (Prior to January 1,1991) <br />5170/TANK <br />(After January 1, 1991) <br />E <br /># Tanks = <br />1986 <br />1987 <br />1988 11989 11990 <br />1991 11992 <br />1993 1994 11995 ( 1996 <br />F <br />A <br />(multiply # by fee for <br />each year applicable) <br />XXXX <br />XXXX <br />S <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />I XXXX <br />XXXX <br />( <br />S <br />Ll <br />STATE SURCHARGE = 356.00 each TANK (Due every 5 years) <br />See California H & S Code, Section Z5287 <br />T <br />Y <br /># Tanks x $56.00 <br />1988 through 1990 <br />1991 <br />through 1996 <br />(Enter amount and year) <br />S <br />C <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Ptace) <br />I TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = <br />L <br />0 <br />CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 378.00/hour (3 hours min./FACILITY) = 3234.00 minimum <br />3 <br />S <br />R <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />EI <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />S <br />PI INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum 3 <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 378.00/hour (3 hours min./FACILITY) = 3234.00 minimum <br />3 <br />R <br />PIPING REPAIR FEE = 378.00/hour (3 hours minimm/FACILITY) _ $234.00 minimum <br />S <br />Mj TRANSFER FEE _ $20.00 I I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I 5 <br />I <br />S <br />C CONSULTATION FEE = 378.00/hr I SAMPLING INSPECTION FEE _ $78.00/hr ; <br />TOTAL DUE 3 <br />FOR OFFICE USE ONLY <br />SWEEPS # I COMPUTER + LOC CODE I DIST CODE I AMOUNT RECEIVED CHECK 4/CASH I RECEIVED 3Y ( DATE RECEIVED <br />I 3 <br />EH 23 032 (REVISED 10-28-93) <br />3 <br />