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SKJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greatness grows here. <br /> FACILITY NAME FACILITY CONTACT NAME <br /> COL <br /> FACILITYADDRESS SITE PHONE WITH AR CODE <br /> N (%1 z0ro 5 <br /> CITY STATE ZJP CODE #OF TANKS AT SITE <br /> Sf ckfon CA q5" <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> UST FEES= $641 Facility Fee+$152 Per Tank 2012 2013 2014 2015 2016 2017 <br /> x3 ka"kg $ tpq} <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$20/TANK $ (00 <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY $ Ii9 <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#(a): TEMPORARY CLOSURE FEE=$4561 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> uftw UP4 V17 $ <br /> TANK ID#(s): PLAN CHECK FEE=$1216/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <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,set. $ <br /> MISCELLANEOUS 84YIi <br /> TRANSFER FEE = $25 $ E6F��'N; <br /> CONSULTATION FEE = $152/HOUR $ L/G 0 VFQ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $152/HOUR $ SANJ <br /> SAMPLING INSPECTION FEE _ $152/HOUR $ h�LT Rc)N,NEODU,y�, <br /> FEES ARE BASED ON THE$152 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OEp NTq� <br /> TOTAL AMOUNT DUE �TMFNT <br /> OFFICE USE ONLY 3Lfe-3- — <br /> SERVICE REQUEST# I FACILDY ID AMOUNT RECEIVED CHECK# I RECEIVED BY I DATE RECEIVED <br /> 1114 <br /> — <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />