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SAN JOAQUIN Environmental He1j1a gy)ent <br /> --COU Wry— <br /> FACILITY NAME FACILITY CONTACT NAME <br /> eAa 8,^ ? � � LTH <br /> FACILITY ADDRESS SITE PHONE#WITH AREA ch0tV IRON IN I ENTAL HE <br /> 16 1-`a `IP-L - i w is W DEPARTMENT <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> S At G is 6:A) CA 9s-z0-7 .7— <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure epair Retrofit <br /> ACTIVE FACILITY <br /> UST FEES= $550 2013 2014 2015 UST FEES= 2016 UST FEES= 2017 2018 <br /> (Facility+1st Tank)+ $583 Facility+ $641 Facility cw� <br /> $130/Tank after 1st $139/Tank +$152/Tank 3 $j <br /> Tank Penalty Assessed for <br /> Unreported Tanks(Based on <br /> Annual Permit Fees) $ <br /> JJ T <br /> TANK SURCHARGE=$20/TANK -� L-7 <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) �p <br /> TANK ID#(s): r 2 CLOSURE FEE=$456/TANK TANKS X$456= $-1 t L— <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): t t.Z t3 PLAN CHECK FEE=$1,216/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,sumps,misc. <br /> PIPING REPAIR FEE=$456/FACILITY (use for piping,under-dispenser containment,ect.) <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 /> O <br /> TOTAL AMOUNT DUE $ t <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CAECK# RECEIVED BY DATE RECEIVED <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />