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SAN JORDUIN CC f PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE' 4 DIVSION <br />n=maeN - rFE UnRKSHFEI <br />C <br />1986 <br />FACILITY CONTACT NAME <br />5 <br />FACILITY SITE NAME <br />Ralph Lee White <br />I <br />Ralph's Market <br />xxxx <br />T <br />xxxx <br />SITE PHONE # with AREA CODE <br />E <br />FACILITY ADDRESS <br />2122 S. Airport Way, <br />(209)464.-8371 <br />A <br />STATE <br />ZIP CODE <br /># of TANKS <br />3 <br />A <br />CITY Stockton, <br />CA <br />95206 <br />at SITE <br />P <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />Ralph Lee White <br />p <br />L <br />Ralph Lee White <br />I <br />1987 <br />APPLICANT PHONE # WITH AREA CODE <br />C <br />A <br />MAILING ADDRESS <br />2230 S. Airport Way <br />(209)464-8371 <br />N <br />T <br />CITY Stockton, <br />STATE <br />CA <br />ZIP CODE <br />95206 <br />TYPE of APPLICATION <br />(Closure, Installation, etc.) Removal <br />1997 <br />F (multiply # by fee for <br />ttnRL <br />C <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />0-702,00 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />xxxx <br />XXXx <br />xxxx <br />xxxx <br />xxxx <br />f xxxxxxxx <br />A <br />C <br />T FACILITY PENALTY FEES ASSESSED (If Applicable) <br />%%%X <br />X%%X <br />XXXX <br />X%%X <br />%XXX <br />S XxxxxxXx <br />t <br />V TANK FEE = 150.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br /># Tanks = _ <br />1987 <br />1988 <br />1989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />1997 <br />F (multiply # by fee for <br />E <br />A each year applicable) <br />xxxx <br />XXXX <br />xxxx <br />X%x% <br />XXXX <br />I---- <br />I TANK PENALTY FEES ASSESSED <br />xxxx <br />xxxx <br />XXXX <br />%X%X <br />XXXX <br />E <br />L <br />I STATE SURCHARGE <br />T <br />Y # Tanks_ x $8.00 <br />1988 through 1990 (256) <br />1991 through 1996 (256) <br />1997 <br />xxxxxxxxxxxxxxxxxxxxxxxxxxx <br />%%XXXXXX%xxxxxxxxxxxxxx <br />S <br />SURCHARGE FOR 1997 <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s)'I_ X 1234.00 = <br />0-702,00 <br />STANK <br />U <br />TEMPORARY CLOSURE (Plan Review 6 Inspections) <br />I.D. #(s) <br />Rf <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) <br />= 1624.00 minimum <br />R <br />REPAIR FEE (Workplan Review -5 Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK)# <br />TANK(s) X $234.00 = <br />1 <br />A- <br />1 <br />TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) $234.00 minimum <br />E <br />R <br />PIPING REPAIR FEE _ $78.00/hour (3 hours minimm/FACILITY) _ $234.00 minimum <br />$ <br />N TRANSFER FEE = $20.00 <br />1 <br />S <br />C CONSULTATION FEE = S78.00/hr <br />FOR OFFICE USE ONLY <br />s!F!!!!m!rmmcaer�mmni.....�!m!!!p_m-.,,.:,_�"•:^.?.m <br />SWEEPS # I COMPUTER # LOC <br />EH 23 032 (REVISED 5.27-97) <br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />SAMPLING INSPECTION FEE _ $78.00/hr <br />AMOUNT RECEIVED I CHECK #/CASH <br />S <br />f <br />TOTAL DUE $702,00 <br />BY I DATE RECEIVED <br />