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SAN JOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greatness grows here. <br /> FACILITY NAME Chevron FACILITY CONTACT NAME Tony Singh <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 25651 Hwy 99 ( 925 ) 783-6102 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Acampo CA 95220 <br /> APPLICANT BILLING NAME Megan Mitchell APPLICANT CONTACT NAME Megan M <br /> APPLICANT MAILING ADDRESS 2535 Wigwam Dr APPLCANT 4PHONE#61$337 WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Stockton Ca 95205 Closure Installation Repair Retmtil 1001331 A-HAZ <br /> ACTIVE FACILITY <br /> USTFEES= $550 2014 2015 UST FEES 2016 UST FEES 2017 VPH UST FEES= 2018 $ <br /> (Facility+1st = $583 - $641 $961 Facility+ <br /> Tank)+$1301Tank Facility+ Facility+ $228fTank <br /> after 1st $139frank $1527ank <br /> Double Wall 81702 $ <br /> Compliant UST <br /> FEES= $680 <br /> Facility+$2281Tank <br /> Tank Penalty $ <br /> Assessed for <br /> Unreported Tanks <br /> (Based on Annual <br /> Pemlit Fees <br /> TANK SURCHARGE-$20 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$49.001 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE_$456/TANK I #TANKS X$456= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID fla);: TEMPORARY CLOSURE FEE=$4561 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins cilons <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 stalls,EVR upgrades, 456.00 <br /> Spill buckets sums mist. <br /> PIPING REPAIR FEE_$4561 FACILITY use for piping.under-0ia neer containment.etc.) <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE _ $1521 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 152/HOUR $ <br /> SAMPLING INSPECTION FEE = $152/HOUR $ <br /> FEES ARE BASED ON THE 1152 HOURLY RATE, TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST FACIuwlo AMOUNT RECEIVED CHECK RECEIVED BY DATE RECENED <br /> 1868 E.Hazelton Avenue I Stockton,Califomia 952051 T 209 468-3420 1 F 209 464-0136 1 www.sjcehd.com <br />