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S N .: J WIN N Environmental Health Department <br /> _ . . _ . COUNTY . _ . <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Flag City Chevron Mr . Que <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br /> 6421 Capitol Avenue ( 209 ) 334 - 0975 <br /> CITY STATE ZIP CODE # OF TANKS AT SITE <br /> Lodi CA 95242 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Deborah Jones <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> 2535 Wigwam Drive 209 461 -6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br /> Stockton CA 95205 Closure Installa0on Repair Retrofit 1001331 <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 + $228rrank <br /> after 1st $ 139rrank $152frank <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 = $201 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 _ $456 / TANK it 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 /> $ <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 /> Split buckets, sumps, misc. <br /> $ <br /> PIPING REPAIR FEE = $ 456 / FACILITY use for piping, underAis enser containment, eta <br /> MISCELLANEOUS <br /> TRANSFER FEE = $ 25 $ <br /> CONSULTATION FEE _ $ 152/ HOUR $ 152 <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 $ 152 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED I CHECK # RECEIVED BY I DATE RECEIVED <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 1 T 209 46&3420 1 F 209 464-0138 1 www. sjcehd .com <br />