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SAN J OAQ U I N Environmental Health Department <br /> --COU NTY-- <br /> Greatness grows here <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE WITH AREA CODE <br /> l W �r- (Qo ) �&q — aq 0 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> —7J CA I J <br /> A?PLICC�T.BILLIIIG NA, M� _ _U S , � J APPLI AN yC NTA�Try,AME <br /> APPLICANT MA LING.ADDRES APP I NTP E#,WIT EA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> �J�SQ C4 �� J ��a" Closure Installation epair Retrofit �� �O v <br /> ACTIVE FACILITY <br /> UST FEES= $550 2014 2015 UST FEES 2016 UST FEES 2017 VPH UST FEES= 2018 $ <br /> (Facility+l st = $583 = $641 $961 Facility+ <br /> Tank)+$130/Tank Facility+ Facility+ $228lTank <br /> after 1st $139/Tank $152/Tank <br /> Double Wall 8 1702 $ <br /> Compliant UST <br /> FEES= $680 <br /> Facility+$2281Tank <br /> Tank Penalty $ <br /> Assessed for <br /> Unreported Tanks <br /> (Based on Annual <br /> Permit Fees <br /> TANK SURCHARGE_$20 1 TANK <br /> $ <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 /> $ <br /> TANK ID#(s): CLOSURE FEE=$456/TANK #TANKS X$456= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$456!FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE=$3,0401 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$456/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, S <br /> Spill buckets,sumps,misc.)J <br /> PIPING REPAIR FEE=$456/FACILITY (use for piping,under-dispenser containment,etc.) <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $152/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $152/HOUR $ <br /> SAMPLING INSPECTION FEE = $1521 HOUR $ <br /> FEES ARE BASED ON THE$152 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $44- <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 />