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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telepho►re: (209) 468-3420 Fax. (209) 468-3433 Web: www.s*jzov.orvjchd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />L"-t+�-c� <br />_2(-,q- $S2-ZZ(� <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />/ o BssB --r2- <br />2 61 3 to S— ^ ( -Z-k (p <br />CITY <br />STATE <br />STATE ZIP CODE <br /># OF TANKS AT SITE <br />// <br />�7 `L <br />CA <br />Closure In latio it Retrofit <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />Installs as of 8/1/07) <br />$125 PER TANK AFTER FIRST TANK <br />Z - <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE #WITH AREA CODE <br />(� L.0 L 14 �L , � ( <br />2 61 3 to S— ^ ( -Z-k (p <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />1—(9CVA- <br />SZ.y d <br />Closure In latio it Retrofit <br />ACTIVE FACILITY <br />TANK ID #(s):CLOSURE FEE _ $294 /TANK # TANKS X $294 = <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />Installs as of 8/1/07) <br />$125 PER TANK AFTER FIRST TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 /TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID #(s):CLOSURE FEE _ $294 /TANK # TANKS X $294 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />CHECK <br />and <br />TANK ID # (s) : I PLAN CHECK FEE = $784 / FACILITY ZI) <br />REPAIR PLAN CHECK <br />TANK ID# s <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring a ui ment, spill buckets, tank sumps, misc.) <br />$ <br />PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ 5 g <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE = $ 98/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 98/ HOUR <br />ALL FEES ARE BASED ON THE $98 HOURLY RATE- TIME TWAT rynrcne .... <br />$ <br />I - uj""Qu IV Hrl <br />UFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID I AMOUNT RECEIVED I CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 08/3/07) <br />