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SAW, >J o U ( E � vlr� � rr► � ntal Health apartment <br /> --- COUNTY--- <br /> Gr' cgotnr� ss grt; � rs 1lerrf' <br /> FACILITY NAME FACILITY CONTACT NAME <br /> K & S Gas & Groceries Mr. Swaren <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br /> 701 E Charter Way ( 209 9334298 <br /> CITY Stockton STATE \ZIP CODE # OF TANKS AT SITE <br /> CA 95208 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> UST FEES = $550 2014 2015 UST FEES 2016 UST FEES 2017 VPH UST FEES = 2018 $ <br /> ( Facility+1st = $ 583 = $641 $961 Facility + <br /> Tank) + $130/Tank Facility + Facility + $228rTank <br /> after 1st $ 139/Tank $15211'ank _ <br /> Double Wail & 1702 $ <br /> Compliant UST <br /> FEES = $680 <br /> Facility + $228/Tank <br /> Tank Penalty $ <br /> Assessed for <br /> Unreported Tanks <br /> (Based on Annual <br /> Permit Fees <br /> TANK SURCHARGE _ $20 / TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.001 FACILITY $ <br /> PERMANENTCLOSURE <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 = $4561 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID # (s) : PLAN CHECK FEE _ $3,040 ! FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID # (a) : <br /> TANK RETROFIT REPAIR FEE _ $456 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $56.00 <br /> Spill buckets, sumps, misc. <br /> PIPING REPAIR FEE _ $456 / FACILITY use for piping, under dis enser containment, etc. <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 $ 456.00 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST 11 1 FACILITY ID AMOUNT RECEIVED I CHECK N RECEIVED BY DATE RECEIVED <br /> 1868 E . Hazelton Avenue ( Stockton , California 95205 T 209 468-3420 F 209 464-0138 1 www. %jcehd .com <br />