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laA UI Environmental Health Department <br /> -- COUNTY- -- <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Dignity Health - St. Joseph ' s Medical Center John Stagg <br /> FACILITY ADDRESS �� ) fl /�t- ' /� C( � + '_n� i SITE PHONE # WITH AREA CODE <br /> ix9e eter -�t°l1✓ Norm 1 ( 209 ) 461 -6818 <br /> CITY STATE ZIP CODE # OF TANKS AT SITE <br /> Stockton CA 95286• C15 (y <br /> APPLICANT BILLING NAME Elite IV Contractors APPLICANT CONTACT NAME Terry Masters <br /> APPLICANT MAILING ADDRESS 2535 Wigwam Dr AP2PLLIICCANT PHON #6% AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br /> Stockton CA 95205 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> UST FEES = $550 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 _ $201 TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM =$49.001 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID # (s) : CLOSURE FEE _ $4561 TANK # TANKS X $456 = <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID # (s) : TEMPORARY CLOSURE FEE _ $456 / FACILITY <br /> i <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID # (s) : PLAN CHECK FEE _ $3,040 / FACILITY <br /> REPAIR PLAN CHECK <br /> I TANK ID # (s) : <br /> TANK RETROFIT REPAIR FEE _ $456 / FACILITY (use for monitoring equipment, cold starts , EVR upgrades , 456 . 0 <br /> Spill buckets, sumps , misc. <br /> PIPING REPAIR FEE = $456 / FACILITY use for piping, under-dispenser containment, etc. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $ 25 $ <br />_ CONSULTATION FEE _ $ 1521 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 /> I <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 l T 209 468-3420 ( F 209 464-0138 l www. sjcehd .com <br /> f' <br /> i <br />