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SAN JOAQUINPUBLIC HEALTH SERVICES - ENVIRONMENTAL TH DIVSION <br /> 0ER"GROUND STORAGE TANK PROGRAM - FEE WORKSHEO <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I Quick And Save #2 Charan Dhillon <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA COOS <br /> & <br /> 2057 South El Dorado Street 209 955-0601 <br /> CITY STATE ZIP CODE # of TANKS <br /> A Stockton CA 95203 at SITE one tank for removal <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L UST owner William Little AGE - <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A 1945 Hammertown Drive Stockton - <br /> N <br /> CITY STATE ZIP CODE TYPE of APPLICATION <br /> T <br /> Stock j ton ca 95210 KC6osure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX- XXXX XXXX XXXX $ XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX 5 XXXXXXXX <br /> ` I <br /> 1 V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 <br /> F (multiply # by fee for 5 <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX <br /> C 5 <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX <br /> L <br /> I STATE SURCHARGE _ <br /> T <br /> Y # Tanks x 58.00 1988 through 1990 ($56) 1991 through 1996 ($56) 1997 <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX $ <br /> C PERMANENT CLOSUREemoval r Authorized Closure-in-Place) TANK I.D. #(s) <br /> L 5 <br /> 0 CLOSURE FEE = $78.0 /hour (3 hours minimum/TANK) # TANK(s)__j_ X - <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R $ <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A 5 <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum <br /> R REPAIR FEE (Workplan Review & 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 = $ <br /> A $ <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum <br /> R=PIPING $ <br /> PAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br /> N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr $ <br /> I <br /> S $ <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY __».._ _._ __ ._». :•__•.. ...- _--.—_:- :,._--:-:_— -:: <br /> :ate_ v :: ::::::• _ .__. _ <br /> SWEEPS # ! COMPUTER # LOC CODE I DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> $ <br /> ... <br /> ............ ...................._..........................._...._.............................._....... :_.n_...................: :::r......................................._............................ <br /> EH 23 032 (REVISED 5-27-97) <br />