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FF <br /> I ED <br /> N A Q U I N Environm nfi 'I Haiti <br /> - ----- COUNTY 'liN Y <br /> J9X020 <br /> FACILITY NAME FACILITY CONTACT NAME <br /> / 7b 9 Sa Na( Comer keoK Powers ENVIRONMENTAL HE, LTH <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE DEBAR <br /> TMENT <br /> aeo2 cOM6C (" P; r, c �q � 461 - sss57 <br /> C17Y STATE ZIP CODE # OF TANKS AT SITE <br /> :5qvck ion CA <br /> AQ�AN)T?QILLI �Glwaa APPLdICApNTFNT�AlCtT.�NlAwM' E <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> S7z..b E , 48ost4e 4Msawt $t°L 48 Z-47414 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br /> WR <br /> 6141 Z004 - Closure Installation Repair Retrofit gtz ? 033 <br /> ACTIVE FACILITY <br /> UST FEES $650 2014 2015 UST FEES 2016 UST FEES 2017 VPH UST FEES = 2018 $ <br /> (Facility+ 1st = $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 =$49.001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Perrnitted Closure in Place <br /> TANK ID # (s) : CLOSURE FEE = $456 / TANK # TANKS X $456 = $ <br /> TEMPORARY CLOSURE <br /> Plan Reviewand Ins actions <br /> TANK ID # (s) : TEMPORARY CLOSURE FEE = $456 / FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ecttons <br /> TANK ID # (s) : PLAN CHECK FEE = $3,040 / 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 sum s misc. <br /> PIPING REPAIR FEE = $456 / FACILITY use for piping, under-dispenser containment, etc. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = $ 25 $ <br /> CONSULTATION FEE _ $ 152/ HOUR $ 152 <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $ 152 / HOUR $ <br /> SAMPLING INSPECTION FEE _ $ 152/ HOUR $ <br /> FEES ARE BASED ON THE 52 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE B-1-LUED-TO-OPLICANT, <br /> TOTAL AMOUNT DUE P trr> �� ckr� � _/ q -ypy� $ � 5Z <br /> OFFICE USE ONLY <br /> SERVICE REQUEST # FACILn"Y ID AMOUNT RECEIVED I CHECK # I RECEIVED BY DATE RECEIVED <br /> 1868 E . Hazelton Avenue ( Stockton , California 95205 T 209 468-3420 1 F 209 464-0138 1 www. sjcehd . com <br />