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SAN JOAQUIN WPUBLIC HEALTH SERVICES - ENVIRONMENTAL OTH DIVSION <br />UNDERGROUND STORAGE TANK R - FEE WORKSHEET <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />I <br />T <br />Waterloo Food & Fuel <br />I Gur al Sidhu <br />E <br />FACILITY ADDRESS <br />SITE PHONE 9 with AREA CODE <br />S <br />3032 E. Waterloo Rd. <br />209-466-5816 <br />& <br />5100.00 <br />Ej <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum <br />CITY <br />STATE ZIP CODE <br />N of TANKS <br />A <br />Stockton <br />CA 95205 <br />at SITE 2 <br />P <br />PI <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />LOil <br />I <br />E ui m n <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE 0 WITH AREA CODE <br />A <br />P.O. Box 950 <br />I <br />209-754-1808 <br />N <br />I XXXX <br />S <br />TCITY <br />STATE! ZIP CODE <br />Sari Andreas <br />TYPE of APPLICATION Closure <br />CA 95249 <br />(Closure, Installation, etc.) <br />TnTA! <br />C'# <br />PERMANENT CLOSURE (Removal or Authorized Closure-in-Place)I TANK I.D. #(s) <br />L <br />0 <br />1986 <br />1987 <br />1988 <br />1 <br />1989 1990 <br />S <br />U <br />ANNUAL FACILITY FEE (Prior to January <br />1, 1991) = <br />5100.00 <br />Ej <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum <br />S <br />PIPING REPAIR FEE = S78.00/hour (3 hours mininaWFACILITY) _ S234.00 minimum <br />S <br />S <br />A <br />( XXXX XXXX I XXXXXXXX <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If <br />Applicable) <br />I XXXX <br />XXXX <br />I XXXX <br />I XXXX <br />S <br />I <br />E+ <br />TANK FEE = 350.00/TANK <br />(Prior <br />to January 1,1991) <br />5170/TANK <br />(After <br />January 1, 1991) <br />4 Tanks = <br />1986 <br />11987 11988 <br />1 1989 ( <br />1990 1991 1992 ( <br />1993 <br />( 1994 ! <br />1995 <br />1996 <br />F <br />(multiply S by fee for <br />XXXX <br />; XXXX I XXXX <br />XXXX <br />S <br />A <br />each year applicable) <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />i XXXX I XXXX <br />XXXX I <br />I ( <br />I <br />g <br />L <br />ISTATE <br />SURCHARGE = $56.00 each TANK <br />(Due every 5 <br />years) <br />See California H & S <br />Code, <br />Section 25287 <br />T <br />IL <br />YI <br />;$ Tanks x 556.00 <br />1988 through <br />1990 <br />1991 through 1996 <br />(Enter amount and year) <br />S <br />C'# <br />PERMANENT CLOSURE (Removal or Authorized Closure-in-Place)I TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) TANK(s) 2 X $234.00 = <br />S468.00 <br />S. <br />PLAN CHECK FEE = 378.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) � TANK I.D. *(s) <br />R <br />R <br />Ej <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum <br />S <br />P <br />INSTALLATION PLAN CHECK (Plan Review 3 Construction inspections) TANK I.D. O(S) <br />Ll <br />A <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) TANK(s) X $234.00 = <br />S <br />N <br />PLAN CHECK FEE = 378.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br />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 = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours mininaWFACILITY) _ S234.00 minimum <br />S <br />N TRANSFER FEE = 520.00 I ; UNAUTHORIZED RELEASE EVALUATION = $78.00/hr I ( 5 <br />I 1 <br />S � � I I <br />C, CONSULTATION FEE = S78.00/hr I I SAMPLING INSPECTION FEE = 578.00/hr I I S <br />TOTAL DUE S 4 <br />FOR OFFICE USE ONLY <br />SWEEPS ( COMPUTER # I LOC CODE I DIST CODE I AMOUNT RECEIVED CHECK x/CASH RECEIVED BY I DATE RECEIVED <br />iE - S <br />EN 23 032 (REVISED 4-6-95) <br />C <br />