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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. Hazelton Ave., Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd FACILITY NAME FACILITY CONTACT NAME C tj v'K-1,) #" 30-7769 /�l /-)'/,ilL FACILITY ADDRESS SITE PHONE # WITH AREA CODE 1 oOS-6 Ty ( z, -)l L 21.3 CITY STATE ZIP CODE # OF TANKS AT SITE J i o c/1-TO/1" CA `% SZ l y -13 APPLICANT BILLING NAME APPLICANT CONTACT NAME '1 (7-2 y 5j1-Ar1i)'1)11) m) rlj APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 3a MA 1A) AL1, Su'fe .S0&, ) `r;s`J -S7) 7 CITY 5 G mrd STATE ZIP CODE CIRCLE WORK TO BE DONE I CONTRACTOR ICC # c/9 Closure Installation Re air Retrofit tccvc,,�cS35i ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $375 / TANK 2008 2009 2010 2011 2012 2013 $ $500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) $ PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) $550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) $ $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED TANK SURCHARGE = $15 / TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY PERMANENT CLOSURE (Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $375 / TANK # TANKS X $375 = TEMPORARY CLOSURE Plan Review and Inspections TANK ID # (s) : TEMPORARY CLOSURE FEE = $375 / FACILITY INSTALLATION PLAN CHECK (Plan Check and Construction Ir TANK ID # PLAN CHECK FEE = $1000 / FACILITY $ REPAIR PLAN CHECK TANK ID # (s) : $ CONSULTATION FEE = $ 125/ HOUR $ TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, S' spill buckets, sumps, misc. $ $ PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) MISCELLANEOUS TRANSFER FEE _ $ 25 $ CONSULTATION FEE = $ 125/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR $ SAMPLING INSPECTION FEE = $ 125/ HOUR $ ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. TOTAL AMOUNT DUE 1 $ 3 OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED LH 23 03Z (RLVI5LU 1/16/2013 by KF)