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SANJOAQUIN <br />COUNTY <br />Greatness grows here. <br />Environmental Health Department <br />FACILITY NAME <br />AgCO A � �� <br />FACILITY CONTA T NAME <br />RQqPe S �Z°� 5 ��- `nor <br />FACILITY ADDRESS <br />13 YO WC, Jo 126 <br />SITE PHOINM # WITH AREA CODE <br />(zQq) 599 - 7600 <br />CITE' <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />I p r` <br />CA <br />/ <br />q- !; , to <br />3 <br />APP ANT BILLING NAME <br />({CO A^ P!� <br />TANK ID # (s) : <br />CLOSURE FEE = $4561 TANK <br />APP k Icy�NnIT CONTAC NAME <br />!<atC e � Svc <br />APPLICANT TYOAILI)A E�O� �j F <br />TANK ID # (s) : <br />APPLICANT NE#WITH ARE CODE <br />lZ <br />�1 <br />1 2014 <br />0 ,5 i q — Q / <br />CITYSTATE <br />2016 <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR LCC # <br />l <br />CA <br />4 536 6 <br />Z S C L{ <br />Closure Insta[Iatjqf Repair Petrofit <br />ACTIVE FACILITY <br />TANK ID # (s) : <br />CLOSURE FEE = $4561 TANK <br /># TANKS X $456 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $4561 FACILITY <br />/ <br />$ "7�6 <br />UST FEES= $550 <br />1 2014 <br />2015 <br />UST FEES <br />2016 <br />LIST FEES <br />2017 VPH UST Z=EES = <br />2048 <br />(Facility+1st <br />= $583 <br />= $641 <br />$961 Facility+ <br />Tank) + $1301fank <br />Facility + <br />Facility + <br />$2281tank <br />after 1st <br />$139rrank <br />$1521Tank <br />Double Wall & 1702 <br />Compliant UST <br />FEES= $680 <br />Facili + $228rrank <br />Tank Penalty <br />$ <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 IN A CUPA PROGRAM =$49.001 FACILITY <br />PERMANENT CLOSURE <br />Removal or Permtned Closure in Place <br />TANK ID # (s) : <br />CLOSURE FEE = $4561 TANK <br /># TANKS X $456 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $4561 FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TANK RETROFIT REPAIR FEE = $456 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />S ill buckets, sum ,mist. <br />$ <br />PIPING REPAIR FEE = $4561 FACILITY use for piping, under -dispenser containment, etc. <br />/ <br />$ "7�6 <br />MISCELLANEOUS <br />TRANSFER FEE = $25 <br />$ <br />CONSULTATION FEE = $ 1$21 HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = S 1521 HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 1521 HOUR <br />FEES ARE BASED ON THE t152 MnORl Y ReTF ME THAT evrec <br />$ <br />TL)TAL AMOUNT DUE S� <br />DFFICE USE ONLY <br />8ERV= REME97 # FACILITY [D AMOUNIr RECEIVED CHECK # RECEEVED BY DATE RECEryEp <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www,sjcehd.com <br />