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F' QUIN -� <br /> c°ti SAN J 0 A Q U I N Environme tal , Health Departm <br /> _ � COUNTY L %Ytso L, m <br /> \9 ( IFoF - Greatness grows here . 1 <br /> FACILITY NAME FACIILITY` CONTACT NAME <br /> 7 1 <br /> FACILITY A DRESSSI ! WO <br /> E PHONE AREA WITH ARCODE ENVIRONMENTAL ALTH <br /> CITY 3spq ,� STATE ZIP CODE # OF TANkS -AT S SITE <br /> CA CA 9S1,03 <br /> APPLICANT BILLING NAME \ APPLICANT CONTACT NAME Q <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> '1d1 ? # rk (,,. r � ! , ( � 1W S60 — �6 <br /> CITY �J � - l STATE7ZI�PCTOD CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br /> 7tCAo Closure Installation Repair etrofit <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 _ $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 /> TANK ID # (s) : TEMPORARY CLOSURE FEE = $456 / FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections <br /> TANK ID # (s) : PLAN CHECK FEE = $3 , 0401 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID # (s) : S aor <br /> TANK RETROFIT REPAIR FEE _ $456 / FACILITY ( use for monitoring equipment, cold starts , EVR 7 <br /> upgrades , �t � 00 <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 = $ 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 $ 4 <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 209464 -0138 1 www. sjcehd . com <br />