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AQEnvironmental Health Department <br /> 11 COUNTY <br /> FACILITY NAMEG � FACILITY CONTACT NAME (� <br /> FACT ITY ADDRESS SITE PHONE # WITH AREA CODE <br /> CITY ���� � STATE ZIP JE # O �NKS AT SITE <br /> �` CA S <br /> APP CANT 131YONG qAME 0*�rCANT CONTACT NAME <br /> v tr rvo l r <br /> ArPt LICAANT M I G�, D E S APPLI AN P N # WITH AREA CODE <br /> ( I 1S ATE MP CODE CIRCLE WORK TO BE DONE ONTRACTOR [CC # <br /> of <br /> Closure Installatio Repair R rofit r 1 1 <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 + $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 /> TANK ID # (s) : PLAN CHECK FEE = $3 , 040 / FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID # (s) : 2 3 <br /> TANK RETROFIT REPAIR FEE _ $456 / FACILITY (use for monitoring equipment, cold starts , EVR upgrades , L� c <br /> Spill buckets , sumps , misc. ) if <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 /> I� <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 ( T 209 468-3420 1 F 209464m0138 I www. sjcelid . com <br />