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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM-FEE WORKSHEET <br /> S FACILITY SITE NAME: Polar Water,Inc. FACILITY Contact: Bob MUoslevict <br /> I <br /> T <br /> E FACILITY ADDRESS: 1029 W. Fremont St. SITE PHONE#+ AREA CODE:(209)466-6766 <br /> & STATE Z[P CODE <br /> A CITY:Stockton, CA 95203 <br /> #OF TANKS AT SITE:2 <br /> P <br /> PAPPLICANT CONTACT NAME: Same as above <br /> L APPLICANT/BILLING NAME:Same as above <br /> 1 <br /> C MAILING ADDRESS:1029 W.Fremont St. SITE PHONE#+ AREA CODE:(209)46&6766 <br /> A <br /> NA ZIP CODE TYPE of APPLICATION: <br /> T CITY:Stockton, CA 95203 (Closure,installation,etc.): REMOVAL <br /> A ANNUAL FACILITY FEE(Prior to January 1,1991)_$100.00 1988 7987 7988 7989 7990 <br /> C xxxx xxxx $ <br /> T <br /> 1 FACILITY PENALTY FEES ASSESSED If applicable) xxxx xxxxI j <br /> S <br /> V TANK FEE=$50.00(TANK (Prior to January 1,1991) $170.00/TANK (After January 1,1991) <br /> E <br /> amranks- 1968 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (mJapry•Mtee/er each $ <br /> A year appacage) <br /> C TANK PENALTY $ <br /> 1 FEES ASSESSED <br /> L <br /> I STATE SURCHARGE_ $56.00 each TANK (Due every 5 years) See California H &S Code,Section 25287 <br /> T #Tanks x$56.00 1986 through 1990 1991 through 1996 <br /> Y (Enter amt. &year) $ <br /> rR <br /> C PERMANENT CLOSURE Removal or Authorized Closure-in Place TANK I.D.#(s) <br /> L $468.00 <br /> D CLOSURE FEE=$78.00/hour 3 hours minimum/TANK #TAN s -r— x$234.00= <br /> S <br /> U TEMPORARY CLOSURE Plan review and inspections) TANK I.D. s <br /> $ <br /> TEMPORARY CLOSURE FEE=$78.00/hour 3 hr minimum/FACILITY) $234 minimum <br /> p INSTALLATION PLAN CHECK(Plan Review&Construction Inspectlons) <br /> A PLAN CHECK FEE=$7SMr(6 hours minimum/FACILITY) _$624 minimum $ <br /> N <br /> R REPAIR FEE(Workplan Review&Construction Inspections) TANK I.D. s <br /> E $ <br /> P TANK LINING REPAIR FEE=$78.00/hour 3 hours minimum/rANK #TAN • _ x $234.00= <br /> A <br /> 1 TANK RET REPAIR FEE=$78.00/hour 3 hours minimum(FACILITY) =$234 minimum <br /> R $ <br /> PIPING REPAIR FEE_$78.00/hour 3 hr minimumlFAdUTY =$234 minimum <br /> MI TRANSFER FEE=$20.00 UNAUTHORIZED RELEASE EVALUATION=$78.00/hr $ <br /> 1 <br /> CONSULTATION FEE=$78.00Mr SAMPLING INSPECTION FEE = $78.00/hr $ <br /> TOTAL DUE $468.00 <br /> FOR OFFICE USE ONLY <br /> SWEEPS# COMPUTER# LOC CODE DIST.CODE AMT.RECEIVED CHECK#/CASH RECEIVED BY DATE RECEIVED <br /> $ <br /> Flt 21032(REVISED 34-93) <br /> Page 11 <br />