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SAN J QQO U I N Environmental Health Department <br /> COUNTY <br /> FACILITY NAME FACILITY CONTACT NAME <br /> t �lU 1'7114 �cY1Ll <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br /> UCS Ic ( - <br /> CITY I STATE ZIP CODE # OF TANKS AT SITE <br /> cA94S Os 13 <br /> APPLICANT BILLING NAME F,-q— �AiF� j APPLICANT CONTACT N ME \ <br /> Cil <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> 1 - � - � <br /> CITY T E ZIP CODE CIRCLE WORK TO BE DONE ONTRACTOR ICC # <br /> Closure installation Repair Retrofit <br /> ACTIVE FACILITY <br /> UST FEES = $641 Facility Fee + $ 152 Per Tank 2012 2013 2014 2015 2016 2017 <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE = $20 / TANK RFCFw Ln <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49. 00/ F C LITY <br /> MAK Z 11 2C 181 <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID # (s) : CLOSURE FEE = $456 / TANK # TATH <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 = $ 1216 / FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID # (s) : <br /> TANK RETROFIT REPAIR FEE _ $456 / FACILITY (use for monitoring equipment, cold starts , EVR upgrades , l <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 _ $ 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 $ 12, <br /> OFFICE USE ONLY <br /> SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEWFED BY DATE ECEI ED <br /> 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468-3420 F 209 464-0138 1 www. sjcehd . com <br />