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SAN JCAQUIN CGUN I— DUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISIUN <br /> UNDERGROUt%WOSTORAGE TANK PROGRAM FE,JIORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Stockton Metro Transit Dist. Beverly Garcia <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 730 E. Channel St. <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95206 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Oil Equipment Service Keith A. Tallia <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> P.O. Box 950 209 754-1808 <br /> CITY STClosure IATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> San Andreas CA 95249 nstallation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1995— 1999 2000 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years,applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$8/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#Is): CLOSURE FEE=$261 !TANK #TANKS X$261 = $2 61 .001 <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> $ <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = <br /> $ <br /> TANK RETROFIT REPAIR FEE =$261 /FACILITY <br /> $ <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = $871 HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 87/HOUR _ <br /> $ I <br /> SAMPLING INSPECTION FEE _ $87/HOUR J <br /> ALL FEES ARE BASED ON THE 587 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY 10 __ AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23032(REVISED 9-21-001 <br />