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+l <br /> f <br /> '¢ S Q N J Q Q Q u , N Environmen_ i Health Department <br /> t u4 <br /> COUNTY- <br /> AUG 2 2 2017 <br /> FACILITY NAME FACILITY CONTACT NAME - _ HEALTH <br /> C'.t e S (our\ • d'p <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1 S -5Col o"\V 0-�l U°I J 9 9 O C <br /> CIw STATE ZIP CODE #OF TANKS AT SITE <br /> c yd CA 9 s 3 t <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> VPS UV'sk" C1 C'S I Cn <br /> APPLICANT MAILING ADDRFESS APPLICANT PHONE#WITH AREA CODE <br /> 0 .6211 os -7 —10 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> 1 C j Z Closure Installation eepai, Retrofit 1 <2 &k <br /> ACTIVE FACILITY <br /> UST FEES= $641 Facility Fee+$152 Per Tank 2012 2013 2014 2015 2016 2017 <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$20/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$456/TANK #TANKS X$456= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$456/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections <br /> TANK ID#(s): PLAN CHECK FEE=$1216/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): S <br /> $ <br /> TANK RETROFIT REPAIR FEE _$456/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE=$456/FACILITY use for piping,under-dispenser containment,ect. $1 <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $152/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $ 152/HOUR $_-^ <br /> SAMPLING INSPECTION FEE = $ 152/HOUR $ <br /> FEES ARE BASED ON THE$152 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ y s(o <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />