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UNOERGROUNn STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY ONTACT NAME <br /> I <br /> SAFEWAY FUEL CENTER NANCY VOVES <br /> FACILITY ADDRESS SITE PHONE N WITH AREA CODE <br /> 2808 COUNTRY CLUB <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> STOCKTON CA 95, 2 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> SAFEWAY,, INC. JEFF LEE @ E.D.A. <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE a WITH AREA CODE <br /> 5918 STONERIDGE MALL ROAD 805 549-8658 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> PLEASANTON CA 94558 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1993—1999 2000— <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X J#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK <br /> $ 625.00 <br /> S <br /> ' TANK PENALTY ASSESSED <br /> TANK SURCHARGE =S81 TANK $ 16.00 <br /> j STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=5101 FACIITY $ <br /> LlO.DO <br /> II PERMANENT CLOSURE <br /> Removal or Pernnted Closure in Place <br /> TANK iD a s : CLOSURE FEE=5261 1 TANK P TANKS X$261 . $ <br /> TEMPORARY CLOSURE N/A <br /> Plan Review and Inspections) <br /> TANK ID a(s). TEMPORARY CLOSURE FEE=$261 1 FACILITY <br /> 'I <br /> INSTALLATION PLAN CHECK <br /> ii Plan Check and Construction inspections) $ <br /> 7 TANK ID#(3): PLAN CHECK FEE_$696 I FACILITY 696.00 <br /> 1 <br /> REPAIR PLAN CHECK N/A <br /> .l <br /> TANK ID#(s): <br /> $ <br /> TANK LINING REPAIR FEE =$261 /TANK C TANKS X$261 = <br /> TANK RETROFIT REPAIR FEE _$2611 FACILITY $ <br /> Is <br /> PIPING REPAIR FEE _$2611 FACILITY <br /> MISCELLANEOUS <br /> 1 $ <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $87/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE 5 871 HOUR $ <br /> 3 <br /> SAMPLING INSPECTIONFEE 5 87I HOUR <br /> S <br /> FEEARE BASED ON THE$82 HOURLYPATE. TIMETMATSXC8eDS FEES PAID WILL SE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST a FACILITY IO AMOUNT RECEIVED CHECKa RECEIVED UY DATE RECEIVED <br /> SR <br /> EN 23 032(REVISED f-214M <br />