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SAN J OAQ U I N Environmental Health Department <br /> COUNTY - <br /> FACILITY NAME � � � FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br /> 17b I , r E71 �avaU6 L201 ) 214 - 14 0 <br /> CITY STATE ZIP CODE # OF TANKS AT SITE <br /> Sccti+� CA q <br /> APCANT ILLIN AME AP CANT CON�'A�T NI�M1QE5 LA a ` <br /> f I <br /> AP LI ANT MAJUVG ADDRESS APPLICANT PRONE # 71TH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br /> Closure Installation a ajr)Retrofit 3f: <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 1 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM = $49.00/ 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 /> 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) : <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, etc. $ 4q <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $ 25 $ <br /> CONSULTATION FEE _ $ 152/ HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $ 1521 HOUR $ <br /> SAMPLING INSPECTION FEE = $ 152/ HOUR 1 $ <br /> FEES ARE BASED ON THE 152 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APP CANT. '] <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY <br /> SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECENED <br /> 1868 E . Hazelton Avenue Stockton , California 95205 1 T 209 468-3420 1 F 209 464 -0138 I www. sjcehd . com <br />