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�ga - IW <br /> Y VANJOAQUIN Environmental 14 - ..m" <br /> l� COUNTY <br /> �-�C' Greatness grows here. <br /> FACILITY NAME FACILITY CONTACT NAME E <br /> !J <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> sbss ( �:NVIRQNME EALTH <br /> CITY `J STATE ZIP CODE #OF TANi-1>377 K I . -� <br /> C 7 CA LL <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 55gino+4j> 001RI464 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 5 0o f77ATV Rab 0 7 I Z <br /> CITYSTATE LP CODE CIRCLE WORK T pE I CONTRACTOR ICC# <br /> D ♦* Closure Installation Repalr etrofit $y p <br /> ACTIVE FACILITY <br /> LIST 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=$49.001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$4561 TANK #TANKS X$455= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$4561 FACILITY Is <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1216 I FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =$4561 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE=$456/FACILITY use for p1ping,under-dispenser containment,ect. $ ' <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $1521 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1521 HOUR $ <br /> SAMPLING INSPECTION FEE = $1521 HOUR $ <br /> FEES ARE BASED ON THE$152 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT Dl1EM ITS F�� 4� x S <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECElVEp <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com <br />