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s <br /> SAN4JOARINitn?a5eq E'VEDt9l <br /> y,. COUNTY--- OCT L 2018 <br /> Greatness �)rwws here. <br /> FACILITY NAME FACILITY CONTACT NAME LT <br /> Kaiser Foundation -Manteca Darryl Cury <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1777 W Yosemite Ave. 209 735-5137 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Manteca CA 95336 1 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Belshire Environmental Services Inc. Mike Ellis <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 25971 Towne Centre Dr. 951 675-7233 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Foothill Ranch Closure Installation epal Retrofit 5254881 <br /> ACTIVE FACILITY <br /> UST FEES= $550 2013 2014 2015 LIST FEES= 2016 UST FEES= 2017 2018 <br /> (Facility+1st Tank)+ $583 Facility+ $641 Facility <br /> $130/Tank after 1st $139/Tank +$152/Tank <br /> $641 <br /> Tank Penalty Assessed for $ <br /> Unreported Tanks(Based on <br /> Annual 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=$1,216/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s):TA0239701 <br /> TANK RETROFIT REPAIR FEE =$456/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $456 <br /> spill buckets,sumps,misc) <br /> PIPING REPAIR FEE=$456/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $152/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1521 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 $1,097.0 <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 F 209 464-0138 1 www.sjcehd.com <br />