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I �Jyb J t r-cul°i ; <br />v <br />SAN JOAQWIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION' <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAME LINCOLN VILLAGE WEST <br />FACILITY CONTACT NAME <br />I <br />CHEVRON <br />SHARON FELTON <br />T <br />E <br />FACILITY ADDRESS 2905 West Benjamin Holt Drive <br />SITE PHONE # with AREA CODE <br />(209) 478-5555 <br />z <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />A <br />Stockton <br />CA <br />95207 <br />at SITE 5 <br />P <br />P <br />L <br />APPLICANT/BILLING NAME <br />Robert H. Lee & Associates, Inc. <br />APPLICANT CONTACT NAME <br />Craig Schafer or Sharyn Mitchell <br />I <br />XXXX <br />xxxx <br />C <br />MAILING ADDRESS <br />1137 North McDowell Boulevard <br />APPLICANT PHONE # WITH AREA CODE <br />(707) 765-1660 <br />A <br />5170/TANK (After January 1, 1991) <br />N <br />E <br /># Tanks = <br />1986 <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />1995 <br />- Petaluma <br />CA <br />94954 <br />(Closure, In6tallation, etc.) <br />TOTAL <br />PERMANENT CLOSURE (Removal or Authorized Closure-in-PlaCe) <br />TANK I.D. #(s) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />A <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) s $100.00 <br />5 <br />Lu <br />TEMPORARY CLOSURE (Pian Review & Inspections) <br />- <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimxNFACILITY) <br />XXXx <br />XXXX <br />XXXX <br />xxxx <br />xxxx S XXXXXXXXXX)XX <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX <br />xxxx <br />XXXX <br />XXXX S XXxxxxxxxXXXx <br />d <br />V <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br /># Tanks = <br />1986 <br />1987 1948 <br />1989 1990 <br />1991 1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />F <br />A <br />(multiply # by fee for <br />each year applicable) <br />XXXX <br />xxxx XXXX <br />XXXX XXXX <br />5 <br />"- <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX XXXX <br />XXXx XXXX <br />S <br />L <br />I <br />STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T <br />Y <br /># Tanks x $56.00 <br />1988 through 1990 1991 through 1996 <br />(Enter amount and year) <br />--- <br />f <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure-in-PlaCe) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE ■ 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) x $234.00 <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = <br />--- - <br />5 <br />5 <br />Lu <br />TEMPORARY CLOSURE (Pian Review & Inspections) <br />- <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimxNFACILITY) <br />5234.00 minimum <br />5 <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE ■ 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) x $234.00 <br />L <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br />$ <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE ■ 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) x $234.00 <br />$ <br />- <br />A <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) r 5234.00 minimus <br />S <br />R <br />PIPING REPAIR FEE = 574.00/hour (3 hours minimum/FACILITY) ` $234.00 minimum <br />Y <br />FM OFFICE USE ONLY <br />SWEEPS # ( COMPUTER <br />....... --'- -- - <br />DIST CORE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE �. 5 <br />