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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D ARTMENT UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET FACILITY NAME FACILITY CONTACT NAME Jim Thorpe Oil Inc. Martin Thorpe FACILITY ADDRESS SITE PHONE # WITH AREA CODE 351 N. Beckman Rd. 209 368-6175 CITY STATE ZIP CODE # OF TANKS AT SITE Lodi CA 95240 5 APPLICANT BILLING NAME APPLICANT CONTACT NAME Jim Thorpe Oil,Inc. Martin Thor -pe APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE P.O. Box 357 20 368-6175 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repair Re ofit Lodi, CA CA 95241-0357 ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $267 / TANK 1997- 1999 2000 2001 2002 TANK RETROFIT REPAIR FEE = $267 / FACILITY $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170)X(#tanks)X(#of years applicable) $ $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR $125 PER TANK AFTER FIRST TANK $ SAMPLING INSPECTION FEE _ $ 89/ HOUR $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $10 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $267 / TANK # TANKS X $267 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $267 / FACILITY INSTALLATION PLAN CHECK TANK ID # PLAN CHECK FEE = $7121 FACILITY REPAIR PLAN CHECK TANK ID # (s): $ TANK LINING REPAIR FEE = $267 / TANK # TANKS X $267 = $ TANK RETROFIT REPAIR FEE = $267 / FACILITY $267.00 PIPING REPAIR FEE = $2671 FACILITY $ MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 89/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR $ SAMPLING INSPECTION FEE _ $ 89/ HOUR ALL FEES ARE BASED ON THE $89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID I AMOUNT RECEIVED -1 CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 3/15/02)