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SAN J O A Q U I N Environmental Health Department <br /> -- --- C O U N T Y---- <br /> FAC1j.ITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br /> CITY STATE ZIP CODE # OF TANKS AT SITE <br /> CA <br /> APPLI NT BILLIVCINAV APPLI A T CONTACT NA E <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE # W II^TH A EA CODE <br /> 116dl *l 1d <br /> CITY <br /> c�ut ` STATE ZIP CODE` Closure CIRCLE <br /> lnstallWo RK TO BEDONECONTRACTOR ICrc # <br /> ACTIVE FACILITY il l�v �t �tiL1 LSC!!` <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 + $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 /> $ <br /> TANK SURCHARGE _ $ 20 / TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $49 .00/ FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID # (s) : CLOSURE FEE = $456 / TANK # TANKS X $456 = <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ections <br /> $ <br /> TANK ID # (s) : TEMPORARY CLOSURE FEE = $456 / FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <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, under4s enser containment, etc.) <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE = $ 25 <br /> CONSULTATION FEE _ $ 152/ HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $ 152 / HOUR $ <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 $ <br /> OFFICE USE ONLY <br /> WIN SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED I CHECK # RECEIVED BY DATE RECEIVED <br /> 1868 E . Hazelton Avenue Stockton , California 95205 ( T 209 468-3420 F 209 464-0138 www. sjcehd . com <br />