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SAQ Q I Environmental Health Department <br /> - -- COU NTY --- <br /> Cir � i; iI ,t P .ss t) rC� :i , j E' re , <br /> FACILITY NAME FACILITY CONTACT NAME <br /> B&G Group Hardeep <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br /> 116 Roth Rd ( 707 326-0369 <br /> CITY STATE ZIP CODE # OF TANKS AT SITE <br /> Lathrop CA 95205 <br /> APPLICANT BILLING NAME Elite IV Contractors APPLICANT CONTACT NAME Megan Mitchell <br /> APPLICANT MAILING ADDRESS 2535 Wigwam Dr APPLICANT PHONE # WITH AREA CODE <br /> 209 461 -6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br /> Lathrop Ca 95205 <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 + $228rrank <br /> after 1st $ 139/Tank $ 152rrank <br /> Double Wall & 1702 $ <br /> Compliant UST <br /> FEES = $660 <br /> Facilit + $228rrank <br /> Tank Penalty $ <br /> Assessed for <br /> Unreported Tanks <br /> (Based on Annual <br /> Permit Fees <br /> TANK SURCHARGE = $20 / TANK <br /> $ <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 $466 = <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 _ $3,0401 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 /> $ I <br /> PIPING REPAIR FEE _ $456 / FACILITY use for piping, under4s 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 5152 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 # I FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br /> II 111 11 W1 <br /> 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468-3420 ( F 209 464-0138 1 www, sjcehd .com <br />