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SAN1JOAQUIN p <br /> Environmental Health Department <br /> _ :: : COUNTY <br /> Greotness grows here , <br /> FACILITY NAME �O / / FACILITY_e IIN TACT Neo7 <br /> 6 e <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br /> ( 'Zo4 ) `�- <br /> CITY STATE ZIP CODE # OF TANKS AT SITE <br /> CA � � � � - 4 <br /> AP LICANT BILLING NAME APPL CANT gONT T NAME <br /> lA R ►� , ►� �. /�o �l e t 1 �r� ~til <br /> APPLICANT MAILING ADDRE S � APPLICANT PHONE # WITH AREA CODE <br /> a. .errr . a/� 1�-C 50) 0 <br /> CITY — STATE Q ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR lCC # <br /> �-�r <br /> 1 rbc G Ciosure Installation Repair Retrofit S ZJV L `J^ I <br /> ACTIVE FACILITY <br /> UST FEES = $550 2014 2015 UST FEES 2016 UST FEES 2017 VPH UST FEES = 2018 $ <br /> (Facility+ 1st = $563 = $641 $961 Facility + <br /> Tank) + $1301Tank Facility + Facility + $2281Tank <br /> after 1st $1391rank $152ITank <br /> Double Wall 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 = $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 $456 = $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID # (s) : TEMPORARY CLOSURE FEE = $456 / FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID # (s) : PLAN CHECK FEE = $3,040 / FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID # (s) : <br /> $ <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, under-dispenser containment, etc. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $ 25 $ <br /> CONSULTATION FEE _ $ 152/ HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $ 152 / HOUR <br /> $ <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 $ YJ6 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST N FACILITY ID AMOUNT RECEIVED I CHECK # I RECEIVED BY DATE RECEIVED <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd . com <br />