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f <br /> �NP�` SAN .DIOAQUIN <br /> Environmental rt <br /> �re <br /> I COUNTY -,, <br /> \ rAclvl '' Greatness grows here . > ( Cl <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br /> VIRONMEN`I ' l` HEAL <br /> CITY STATE MP CODE # OF TANKS AT SI <br /> r� C CA S 3 �- fa ``( <br /> 'D I <br /> APPLICANT "Pem! J� S [ r � � ce., '� APPLICANTCONTACTQ e. 1 , a Sa^,ic 4e L <br /> APPLICANT MAILING �AI'DDRESS APPLICANT PHONE # WITH AREA CODE <br /> 3e& 1 C+ &5 — 0803 <br /> CITY STATE LP CODE CIRCLE WORK TO BE DONECONTRACTOR ICC # <br /> Ari + .a c k CA Ci q570 S 1 Close InstallaUo Re ai Retrofit 572 <br /> Sd jll 5' � <br /> ACTIVE FACILITY <br /> UST FEES = $550 2014 2015 UST FEES 2016 UST FEES 2017 VPH UST FEES = 4018 $ <br /> (Facility+1st = $583 = $641 $961 Facility + <br /> Tank) + $130ITank Facility + Facility + $228/Tank <br /> after 1st $139/Tank $152rrank <br /> Double Wali 81702 $ <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 _ $201 TANK $ <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 /> 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, $$ <br /> Spill buckets, sumps, misc.) <br /> PIPING REPAIR FEE _ $456 / FACILITY use for piping, underAis enser containment, etc. $ <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 $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST O FACILITY ID AMOUNT RECEIVED I CHECK # I RECEIVED BY DATE RECEIVED <br /> 1868 E. Hazelton Avenue Stockton , California 95205 1 T 209 468-3420 F 209 464-0138 1 www. sicehd .com <br />