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SAN JOAQUIN CMMTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br />UNDVgROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAME <br />FACILITY CON NAME <br />I <br />T <br />F MART #1 <br />FRANK QUINTA <br />1989 <br />1990 <br />E <br />FACILITY ADDRESS <br />SITE PHONE 2 with AREA CODE <br />i <br />2072 W. YOSEMITE, MANTECA CA <br />(209) 823-7225 <br />XXXX <br />XXXX <br />CITY <br />STATE <br />ZIP CODE <br />P of TANKS <br />A <br />P <br />MANTECA <br />CA <br />at SITE 6 <br />E <br />TEMPORARY CLOSURE FEE a 578.00/hour (3 hours minimum/FACILITY) <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />I <br />CRISP PETROLEUM ENVIRONMENTAL <br />LEONARD ISP <br />E. <br />i <br />V <br />C <br />MAING ADDRESS <br />APPLICANT PHONE WITH AREA CODE <br />A <br />P.O. BOX 30487 <br />209 931-1828 <br />0 Tanks a <br />1986 <br />1 1987 <br />T <br />CITY <br />STATE <br />ICA <br />ZIP CODE <br />TYPE of APPLICATION <br />1994 <br />STOCKTON <br />195213 1 <br />(Closure, Installation, etc.) REPAIR <br />TOTAL <br />PERMANENT CLOSURE (Removal or authorized Closure -in-place) <br />TANK I.O, it(s) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />A <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) a 5100.00 <br />CLOSURE FEE a 578.00/hour (3 hours minimum/TANK) <br />S TANK(s) X (234.00 a <br />S <br />S <br />XXXX <br />XXXX <br />U <br />i <br />A <br />R <br />C <br />E <br />TEMPORARY CLOSURE FEE a 578.00/hour (3 hours minimum/FACILITY) <br />T <br />I <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />I X)= <br />i <br />V <br />TANK FEE a 550.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br />0 Tanks a <br />1986 <br />1 1987 <br />1988 � 1989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1994 <br />1 1995 1996 <br />F <br />(multiply 4 by fee for <br />XXXX <br />XXXX <br />I <br />I <br />I <br />S <br />A <br />each year applicable) <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />I <br />S <br />L <br />I <br />STATE SURCHARGE a 556.00 each TANK (Due every 5 years) See California N & S Code, Section 25287 <br />T <br />T <br />4 Tanka A 556.00 <br />1988 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />S <br />C <br />PERMANENT CLOSURE (Removal or authorized Closure -in-place) <br />TANK I.O, it(s) <br />L <br />A <br />0 <br />CLOSURE FEE a 578.00/hour (3 hours minimum/TANK) <br />S TANK(s) X (234.00 a <br />S <br />S <br />U <br />TEMPORARY CLOSURE (Alan Review 3 Inspections) <br />TANK I.D. S(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE a 578.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />S <br />P <br />INSTALLATION PLAN CAECX (Plan Review d Construction Inspections) <br />TANK I.O. 0(s) <br />L <br />A <br />P <br />TANK LINING REPAIR FEE a 578.00/hour (3 hours minimum/TANK) <br />N <br />PLAN CHECX FEE a 578.00/hour (8 hours minimum/FACIL(TY) a 5624.00 minimus <br />f <br />R <br />REPAIR FEE (Workplan Review I: Construction Inspections) <br />TANK I.D. 8(s) <br />E <br />P <br />TANK LINING REPAIR FEE a 578.00/hour (3 hours minimum/TANK) <br />X TANK(s) X 5234.00 a <br />f <br />A <br />I <br />TANK RETROFIT REPAIR FEE a 578.00/hour (3 hours min./FACILITY) a 5234.00 minimum <br />i - <br />R <br />PIPING REPAIR FEE a 578.00/hour (3 hours minimua/FACILITY) a 504.00 minimum <br />S <br />N TRANSFER FEE a 520.00 I I UNAUTHORIZED RELEASE EVALUATION a S78.00/hr I f <br />I � <br />S <br />ClCONSULTATION FEE a 578.00/hr SAMPLING INSPECTION FEE a 578.00/hr S <br />TOTAL DUE I S <br />FOR OFFICE USE ONLY <br />EN 23 032 (REVISED 10-28-93) 0 <br />3 <br />