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SAN J OAQU I N Environmental Health Department <br /> C OU N T Y------ <br /> FACILITY NAME FACILITY CONTACT NAME <br /> fco(t7 'C.V1 Ig,(I r <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> CA 3 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> (U <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> aC 01 S 3 1 Closure Installationepai Retrofit SZ�o y <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): 7- PLAN CHECK FEE=$1216/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <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. <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 Is `7',5 J <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.sicehd.com <br />