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A Q Q r� �rirOr>l� nfl Health Department <br /> C O U N T Y -- <br /> FACILITY NAME FACILITY CONTACT NAME <br /> JD Service Station Jawinder Singh <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br /> 9015 W Walnut Grove Rd ( 209 794-8993 <br /> CITY STATE ZIP CODE # OF TANKS AT SITE <br /> Thornton Cq 95686 <br /> APPLICANT BILLING NAME Elite IV Contractors APPLICANT CONTACT NAME Megan Mitchell <br /> APPLICANT MAILING ADDRESS 2535 Wigwam Dr A�SiCANT PHOWITH AREA CODE <br /> CITY Stockton STATE ZIP CODE CIRCLAE61NEt/WORK 7TO BE DONE CONTRACTOR ICC # <br /> Ca 95205 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 + $228/Tank <br /> after 1st $139/Tank $152/Tank <br /> Double Wall & 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 /> 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 _ $3,040 / FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID # (s) : <br /> TANK RETROFIT REPAIR FEE _ $456 / FACILITY (use for monitoring equipment, cold starts , EVR upgrades , 456.00 <br /> Spill buckets, sumps, misc . <br /> PIPING REPAIR FEE _ $456 / FACILITY (use for piping, underAispenser containment, etc.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $ 25 $ <br /> CONSULTATION FEE _ $ 152/ 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 $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST # FACILITY to AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br /> 1868 E . Hazelton Avenue Stockton , California 952051 T 209 468-34201 F 209 464 -0138 1 www.sjcehd .com <br />