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Piping Only <br /> SAN JOAQUIN Ca PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE DIVSION <br /> UNDfttROUMD STORAGE TANK PROGRAM - FEE WORKSHEET v <br /> 5 FACILITY SITE NAME FACILITY CONTACT NAME <br /> 1 ARCO Facility 5569 Prestige Stations Inc. 5289 <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & 3518 E. Hammer Lane 209 474-9343 <br /> CITY STATE ZIP CODE I if of TANKS <br /> A Stockton CA 95210 at SITE 3 <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L Thomas Schoensi--in <br /> Tait & Associates <br /> C NAILING ADDRESS APPLICANT PHONE # WITH AREA COOS <br /> A 1001 Gal Way, Ste. 404 1rTYPS <br /> - <br /> N <br /> T CITY STATE ZIP CODE of APPLICATION <br /> Concord 452 ure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A %%X% xxxx 5 <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx )0= 5 <br /> I <br /> V TANK FEE • S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1 1996 <br /> F (multiply A'byby fee for <br /> A each year applicable) X%XX xxxx 5 <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx 5 <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> T # Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> f S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE - S78.00/hour (3 hours minimum/TANK) # TANK(s)_ x S234.00 S 234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum <br /> 5 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - S78.00/hour (8 hours minima /FACILITY) 5624.00 minimum S 624.00 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) _ X $234.00 = S <br /> A <br /> 1 TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum 5 <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION - 478.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE 578.00/hr SAMPLING INSPECTION FEE - S78.00/hr 5 <br /> TOTAL DUE a 858.00 <br /> FOR OFFICE USE ONLY <br /> ax_ __.._...___......._.._.._...._......._......_................_................_:_.._._.._._.. .___...... .._....._.. _._..:-:.. <br /> .w6_...n_-��_�.__—a,—.,..,_„_..,_:.:_•___..._.._.._._..__.__.._.. ...=!s:...,�,,�::::,ui!!F..:,=.... ....:......:...._s... .:c::E:m <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE I AMOUNT RECEIVED CHECK #/CASH RECEIVED BY ,.,. OATS RECEIVED 3 <br /> S <br /> .._T.r!::�:.::__;__.._.__._..____. 3 <br /> __ ....._...... n.....r... .........._......v:e c::-:e.......�... _, m::::::::u...0 !L[!! V::=L�-=iFi, v, amu, aev_s- <br /> ...::::::.....v ..L_vu.�__'__._!................!._uv..A..__..J '':::.:i_::i:::z_ :::::v ......... ._..:::.........._::- <br /> EH 23 032 (REVISED 10-28-93) �,,,� <br /> �.s <br />