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rfp,QU1N `G� /'1 A NsJ OAQ U I N Environmental Health Department <br /> ( ��^ Z <br /> " tf'dtI'?' ' � — COUNTY— <br /> °�rivdR�°� Greatness grows here. <br /> FACILITY NAME FACILITY CONTACT NAME <br /> coo -kcA Y 0. eY <br /> ILITYADDR SS SITE PHO # WITH AREA COD <br /> eY Ll, �Q <br /> CI I STATE ZIP CODE I # OF TANKS AT SITE <br /> G CA c15 LOU <br /> APPLICANT BILLING NAME APPLICANT CONTACT AME <br /> an ren <br /> APPLICANT MAILING ADDRESS APPLICANT ONE # WITH AREA CODE <br /> S P 2 <br /> CITY STATE ZIP CODE CIRCLE 9RK TO-2 BE DONE CONTRACTOR ICC # <br /> Closure Installatlon Repair RetrofitpA <br /> ACTIVE FACILITY P jpN !M— <br /> UST FEES = $641 Facility Fee + $152 Per Tank 2012 2013 2014 2015 2016 �' (@ 4 h <br /> $JAN 2 ` 2018 <br /> TANK PENALTY ASSESSED $ rAL HEALTH <br /> TANK SURCHARGE = $20 / TANK E<`NIF ®NM ; .MINT <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID # (s) : CLOSURE FEE = $456 / TANK # TANKS X $456 = <br /> TEMPORARYCLOSURE <br /> Plan Revlew and Inspections) <br /> $ <br /> TANK ID # (s) : TEMPORARY CLOSURE FEE _ $456 / FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <br /> TANK ID # (s) : PLAN CHECK FEE = $1216 / FACILITY is <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 III buckets, sumps, mist. <br /> $ <br /> PIPING REPAIR FEE = $456 / FACILITY use for piping, under-dispenser contalnment, ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $ 25 $ <br /> CONSULTATION FEE _ $ 152/ HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $ 152 / 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 DUE is <br /> OFFICE USE ONLY <br /> SERVICE REQUEST # FACILITY ID I AMOUNT RECEIVED I CHECK # RECEIVED BY I DATE RECEIVED <br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />