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I . 0 0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES — ENVIRONMENTAL HEALTH DIVISION UNDERGROUND STORAGE TANK PROGRAM — FEE WORKSHEET S I FACILITY SITE NAME: JIM THORPE OIL, INC. FACILITY CONTACT NAME: RICHARD THORPE T E FACILITY ADDRESS: 351 N. BECKMAN RD. SITE PHONE # + AREA CODE:(209)368-6175 & TANK LINING REPAIR FEE= $78.00/hour(3 hours minimum/TANK STATE ZIP CODE A CITY: LODI, CA 95240 # OF TANKS AT SITE: 5 P V E TANK FEE = $50.00/TANK (Prior to January 1, 1991) $170.00lrAN K (After January 1, 1991) PIPING REPAIR FEE = $78.00/hour 3 hr minimum/FACIUTY sofTanks = P L APPLICANT/BILLING NAME: JIM THORPE OIL, INC. APPLICANT CONTACT NAME: RICHARD THORPE I C A MAILING ADDRESS: P.O. BOX 357 SITE PHONE # + AREA CODE: (209)368-6175 N CITY: LODI STATE I ZIP CODE I TYPE of APPLICATION: T CA 95240 (Closure, installation, etc.):WIRING/ADD A INSTALLATION PLAN CHECK (Plan Review& Construction Inspections) TANK I.D. #(s) 1986 1987 1988 1989 1990 E ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 xxxx xxxx $ C TANK LINING REPAIR FEE= $78.00/hour(3 hours minimum/TANK T A $234.00 1 'Oxx xxxx $ I FACILITY PENALTY FEES ASSESSED If applicable) V E TANK FEE = $50.00/TANK (Prior to January 1, 1991) $170.00lrAN K (After January 1, 1991) PIPING REPAIR FEE = $78.00/hour 3 hr minimum/FACIUTY sofTanks = 1986 1987 1988 1989 1991 1992 1993 1994 1995 1996 F (multiply # by fee for each $ A year applicable) I C TANK PENALTY $ 1 FEES ASSESSED L I STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 T _x $56.00 L(Enter 1986 through 1990 1991 through 1996 Y mt. & year) $ C PERMANENT CLOSURE Removal or Authorized Closure -in Place TANK I.D. s L $ O CLOSURE FEE = $78.00/hour 3 hours minimum/TANK # TANK(s) x $234.00 = S U TEMPORARY CLOSURE Plan review and inspections) TANK I.D. s R $ TEMPORARY CLOSURE FEE = $78.00/hour 3 hr minimum/FACILI $234 minimum P INSTALLATION PLAN CHECK (Plan Review& Construction Inspections) TANK I.D. #(s) TANK I.D. s E AN PLAN CHECK FEE = $78/hr (8 hours minimum/FACILITY) _ $624 minimum $ P TANK LINING REPAIR FEE= $78.00/hour(3 hours minimum/TANK R REPAIR FEE Wo an Review& Construction Inspections) TANK I.D. s E $ I#TANK49) P TANK LINING REPAIR FEE= $78.00/hour(3 hours minimum/TANK — x $234.00= A $234.00 1 TANK RETROFIT REPAIR FEE= $78.00/hour 3 hours minimumAFACILITY = $234 minimum R $ PIPING REPAIR FEE = $78.00/hour 3 hr minimum/FACIUTY = $234 minimum IZED RELEASE IIM I TRANSFER FEE= r CONSULTATION FEE)—o $78.00/hr SAMPLWGRNSPECTION FEEVAt$�T�mNr=$78.00/hr $ $_ TOTAL DUE FOR OFFICE USE ONLY SWEEPS # COMPUTER # LOC CODE DIST. CODE AMT. RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED $ EH 23 032 (REVISED 3-1-93)