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SAN,,JOAQUIN Environmental Health <br /> WftED <br /> Greatness grows ' �>re. <br /> JAN U 8 2018 <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FE-h EX G NH HF.q� <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE �. <br /> —c-b-53— µov <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> -rrz, CA 85377 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> b)Ain otib �'N41l4els-m14 QAF-11440,11 LV17— <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 9�;17C s R--t> 0 7- 17-- <br /> CITY STATE I ZIP CODE CIRCLE WORK T DO E CONTRACTOR ICC# <br /> -1+.4IN D 13 Closure Installation Repair etrofit 8110 <br /> ACTIVE FACILITY <br /> UST FEES= $641 Facility Fee+$152 Per Tank 2012 2013 2014 2015 2016 2017 <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$201 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=$4561 TANK #TANKS X$456= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$456 1 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s) : PLAN CHECK FEE=$1216/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$456 1 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,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $1521 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 L- EjiT9 FCU- 414S ;c ,&T $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> 1868 E. Hazelton Avenue I Stockton. California 95205 1 T 209 468-3420 1 IF 209 464-0138 1 www.sicehd.com <br />