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`Z Environmental Health')V girt IntS Q N � , Q Q ( N <br /> _ i''. — COUNTY— I <br /> rows ere.Greatness h ,! k { <br /> 9 � zivl <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS O p SITE PHONE # WITH AREA CODE <br /> 2. Y30 ADe f onn � O / 1tW ( Z.t34 ) 4? 30 18 <br /> CITY j STATEZIP CODE # OF TANKS AT SITE <br /> C� <br /> �j rGl G <br /> ICA �- <br /> APPIJCANT BILLING NAME APP CANT CONTACT AME <br /> APPLIGANrMAILING Auunc" APPLICAN HONE # WITH AREA CODE <br /> 'LH ? o Jwc' 1064410 pow 209 5' 99 - 0 / <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br /> 'raC C 9 .53 Closure Installago6 Repai Retrofit S 2' S0 4 S I <br /> ACTIVE FACILITY <br /> UST FEES c 5550 2014 2015 UST FEES 2016 UST FEES 2017 VPH UST FEES = 2018 $ <br /> (Fadlity+lst a $583 = $641 $961 Facility + <br /> Tank) + $130rrank Facility + Facility + $228/Tank <br /> after 1st $13Wrank $152/Tank <br /> Double Wall 81702 $ <br /> Compliant UST <br /> FEES = $680 <br /> Facility + $228fTank <br /> Tank Penalty $ <br /> Assessed for <br /> Unreported Tanks <br /> (Based on Annual <br /> Permit Fees <br /> TANK SURCHARGE = $20 / TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM =$49.00/ FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure In Place <br /> TANK ID # (s) : CLOSURE FEE = S466 / TANK # TANKS X $456 = $ <br /> TEMPORARYCLOSURE <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 _ $3,040 / 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 sum s, misc.) �`-i6 <br /> $ <br /> PIPING REPAIR FEE _ $456 / FACILITY use for piping, under4ie user containment. eta) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $ 25 $ <br /> CONSULTATION FEE _ $ 152/ HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S152 / HOUR $ <br /> SAMPLING INSPECTION FEE _ $ 152/ HOUR $ <br /> FEES ARE BASED ON THE $152 HOURLY RA . T E THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE S <br /> OFFICE USE ONLY <br /> SERVICE REQUEST 0 1 FACIUTY ID I AMOUNT RECEIVED I CHECK # I RECEIVED BY DATE RECEIVED <br /> 1868 E. Hazelton Avenue Stockton , Califomia 95205 ( T 209 468-3420 F 209 464-0138 1 www.sjcehd .com <br />