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it itr !9+ <br />Od <br />It d <br />Ie <br />If A� SANJ OAQU <br />t <br />FACILITY NAME <br />cA AN< 051ec To 5jc"' <br />FACILITY CONTACT NAME <br />SSG SHEL-IIII�N <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />�000 .57'/sYI San� i1'.p <br />(,Za ) 83 --53.3 t <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />S7oGX?oN <br />CA <br />CITY` <br />STA <br />APPLICANT BILLING NAME <br />ACTIVE <br />APPLICANT CONTACT NAME <br />2014 <br />2015 <br />BE,Qitl E DL SO <br />APPLICANT MAILING ADDRESS <br />o 7N 5 :51ol 6R W2 n/ A <br />Yom', LJ�vi r <br />APPLICANT PHONE # WITH AREA CODE <br />$o 3;z - 6 <br />VPH UST FEES = <br />$961 Facility+ <br />$228/Tank <br />2018 <br />oz <br />CITY` <br />STA <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />ICC # <br />qE <br />�CONTRACTOR <br />Closure Installation <br />Repair <br />Retrofit <br />FACILITY <br />UST FEES= $550 <br />(Facility+1st <br />Tank) + $130/Tank <br />after 1st <br />2014 <br />2015 <br />UST FEES <br />= $583 <br />Facility + <br />$1391Tank <br />2016 <br />UST FEES <br />= $641 <br />Facility + <br />$1521Tank <br />2017 <br />VPH UST FEES = <br />$961 Facility+ <br />$228/Tank <br />2018 <br />$ <br />Double Wall & 1702 <br />Compliant UST <br />THAT EXCEEDS FEES PAID WILL BE BII.LED TO APPLICANT. <br />$ <br />FEES = $680 <br />Facility + $228/Tank <br />Tank Penalty <br />Assessed for <br />$ <br />Unreported Tanks <br />(Based on Annual <br />Permit Fees <br />TANK SURCHARGE = $201 TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />$ <br />TANK ID # (s) <br />TANK ID # <br />CLOSURE <br />Construction <br />CLOSURE FEE _ $4561 TANK <br />TEMPORARY CLOSURE FEE _ $456 / F <br /># TANKS X $456 = <br />TANK ID # (s) I 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 />for <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE _ $ 152/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 152 /HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 152/ HOUR <br />$ <br />FEES ARE BASED ON <br />THE $152 HOURLY <br />RATE, TIME <br />THAT EXCEEDS FEES PAID WILL BE BII.LED TO APPLICANT. <br />TOTAL AMOUNT DUE I $ <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />1868 E. Hazelton Avenue � Stockton, California 95205 ( T 209 468-3420 � P 209 964-0138 1 <br />www.sjcehd.com <br />