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SAN . J O A Q U I N Environmental Health Department <br /> -- COUNTY <br /> Greatness grows here . <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 0 5 c e0A W9Gs� l�U SV G /olik� % cps;7` <br /> FACILITY ADDRESS SITE PHONE # Wlj� AREA CODE (� <br /> Sim;7 /1Olr �2 �9 S7` czo9 � �SZ - plGo o & <br /> CITY STATE ZIP CODE # OFTANKS AT SITE <br /> Sfoc�T a CA 45Sz o 3 Owe, <br /> APPLICANT BILLING NAME �.y� � %-� APPLICANCONTACT � Ems` <br /> APPLICAN �1� A RE/SS,! APPLICA'N'T/PHOZ WITH AREA CODE/ <br /> CITY Sso <br /> 6/c/ 010) <br /> S �� �ZIUOD <br /> Ir <br /> WORK TO BE DONE" CONTRACTOR ICC # <br /> V '��)�- rt/ Closur Installation Repair Retrofit <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 = $660 <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 /> P ENT CLOSURE <br /> Removal r Permitted Closure in Place <br /> TANK ID # (s) : ! CLOSURE FEE = $456 / TANK # TANKS X $456 = $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ecfions <br /> TANK ID # (s) : TEMPORARY CLOSURE FEE _ $456 / FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID # (s) : PIAN 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, mise. <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 $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br /> 1RFR F Ha7altnn Avenue 1 Cfnrlrfnn rolifnrnio OWMIC; I T 7n0 nFa Qn7n I c nnn nen n4 00 1 <br />