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7r S A . J O U I P <br /> r� v � rOnrr� � r� �� � l� � � � � h Department <br /> COUNTY <br /> xl�b pp <br /> �' a . i �s:t, rfi ,�✓ t�: ( r >;7 'Iir '! r' r <br /> FACILITY NAME FACILITY CONTACT NAME <br /> CA AN cTo tgr S F � .SHEt 7oN <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br /> ,, Ooo .1 7//n RIP too ) � 3 - 5331 <br /> CITY STATE ZIP CODE / 7"'r"05'FF TANKS AT SITE <br /> S7oG�{?oN CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 77� E4efl 2 NG , .BERN E of S <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> o474 5; SHE W I%f A Y450 am T <br /> CITY` STA E ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICG # <br /> Y TVt /Q G/� 3 e�b 3 Closure Installation Repair Retrofit 3 <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 ) + $ 1301Tank 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 = $201 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY W A CUPA PROGRAM =$49. 001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID # (s) : CLOSURE FEE = $4561 TANK # TANKS X $456 = $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID # (s ) : TEMPORARY CLOSURE FEE _ $456 1 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <br /> TANK ID # (s) PLAN CHECK FEE = $3 , 040 / FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID # (s) : <br /> TANK RETROFIT REPAIR FEE _ $4561 FACILITY (use for monitoring equipment, cold starts , EVR upgrades , $ <br /> 5 ill buckets, sum s, 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 /> 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 # FACILITY ID AMOUNT RECEIVED CHECK # 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 />