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C <br /> r <br /> OPgUIN C �7 I� <br /> Q' ;f� S A N J O A Q U I N Environmental HealthDepartment <br /> " In1 I <br /> 9A111 <br /> . COUNTY— Dr , <br /> -. AI , ® � 2020 <br /> ron�`PJ Grenfne .ss grows here , <br /> FACILITY NAMEFACILITY CONTACT NAME <br /> /; yyp- �/a �C -(' c I�a' �-sL \ '=`' #' �` LNVI I� OI�� iU PI'S T, � L I-� ��`� LTH !I <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE n- In') T N i <br /> 2L 1✓C `c tom` `(L i`�GtF1 IA" t/ cZo`f � 3U) f <br /> CITY p STATE ZIP CODE _ `yam # OF TANKS AT SITE <br /> \ CA <br /> APttttt1I ANT BILLING NAME APPLIGA T CONTAC NAME <br /> APPLI AN MAILING ADDLtXSAPPLICANT PHONE # WITH AREA CODES <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br /> ( ' L G ' Closure Installation Repair Retrofit 3�< �� C <br /> ACTIVE FACILITY <br /> UST FEES = $650 2014 2015 UST FEES 2016 UST FEES 2017 VPH UST FEES = 2018 $ <br /> (Facility+ lst = $583 = $641 $961 Facility + <br /> Tank) + $ 130/Tank Facility + Facility + $228/Tank <br /> after 1st $ 139/Tank $ 152/Tank <br /> Double Wall & 1702 $ <br /> Compliant UST <br /> FEES = $680 <br /> Facility + $228/Tank <br /> Tank Penalty $ <br /> Assessed for <br /> Unreported Tanks <br /> (Based on Annual <br /> Permit Fees <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 /> $ <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, 040 / FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID # (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, underdis enser containment, etc.) <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 $ <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 T 209 468 -3420 1 F 209 464-0138 1 www. sjcehd . com <br />