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SAN J O A Q U ( N Environmental Health Department <br /> _ COUNTY <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILIV ADDRESS SITE P14ONE # WITH AREA CODE <br /> � QQ <br /> CITY STATE ZIP CODE # OF TANKS AT SITE <br /> 46 LN <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> alit <br /> APPLICANT MAILING AD RE�SSr L) iii APPLICANT�PHOdNE #,i WITH At A CODE <br /> Auld CITY 7�1 STATE ZIP CODE ��CIRCLE iWORKdTO- <br /> JBEE DONE CONTRACTOR ICC # <br /> /� <br /> D C- d r t Closure Installation Repair etro <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 / TANK <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 /> TANK ID # (s) : CLOSURE FEE = $456 / 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. <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 $ ` ol <br /> OFFICE USE ONLYIiiiiiiiiiiin <br /> SERVICE REQUEST # FACILITY ID AMOUNT RECEfVED CHECK # RECEIVED BY DATE RECEIVED <br /> t <br /> 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468-3420 F 209 464 -0138 www. sjcehd . com <br />