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S Q N J Q Q Q U I N Environmental Health Department <br /> - - - COUNTY <br /> FACT NAME �� FACILITY CONTACT NAME <br /> ' (T JSIrLs • � � VCQGQ�� <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br /> CITY STATE ZIP CODE # OF TANKS AT SITE <br /> CA <br /> APPLICANT.BILLING NAME <br /> � 1SLl APPLIC CON ACT N ME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONEWiTHEA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE /CONTRACTOR ICC # <br /> L <br /> S' 5 Closure Installation a air Retrofit <br /> ACTIVE FACILITY <br /> UST FEES = $550 2014 2015 <br /> UST FEES 2016 UST FEES 2017 VPH UST FEES = 71 <br /> 018 $ <br /> (Facility+ 1st = $583 = $641 $961 Facility + <br /> Tank) + $ 130/Tank Facility + Facility + $228/Tank <br /> after 1st $139ffank $1521Tank Double Wall & 1702 $ <br /> Compliant UST <br /> FEES = $680 <br /> Facility + $228ft'ank <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 IN A CUPA PROGRAM =$49.00! FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID # (s) : CLOSURE FEE _ $4561 TANK # TANKS X $456 = <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID # (s) : TEMPORARY CLOSURE FEE = $456 / FACILITY <br /> IIIIIINSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections $ <br /> TANK ID # (s) : PLAN CHECK FEE _ $3,0401 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID # (s) : <br /> $ <br /> TANK RETROFIT REPAIR FEE _ $456 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br /> Spill buckets, sumps , misC. <br /> PIPING REPAIR FEE _ $4561 FACILITY use for piping, under4s enser containment, etc. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $ 25 <br /> $ <br /> CONSULTATION FEE _ $ 1521 HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $ 152 J HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $ 1521 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 q I FACILnY ID AMOUNT RECEIVED CHECK R RECEIVED BY I DATE RECEIVED <br /> 1868 E. Hazelton Avenue Stockton , California 95205 T 209 468-3420 F 209 464-0138 1 www.sjcehd .com <br />