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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www-sigov.org/ehd FACILITY NAME APPLICANT CONTACT NAME FACILITY CONTACT NAME " �L +f 4�J ��ttc 1C S 4C-4- APPLICANT PHONE # WITH AREA CODE FACILITY ADDRESS 2006 SITE PHONE # WITH AREA CODE 1 e)5543 fi CITY y STATE -2w9 952— ZZi3 ZIP CODE # OF TANKS AT SITE 6�Ck Closur Tnstt.; l>"att6'�n epair Retrofit CA APPLICANT BILLING NAME APPLICANT CONTACT NAME $500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) 2002 APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2005 2006 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # () �� L,,4 qSZ YLj Closur Tnstt.; l>"att6'�n epair Retrofit --r7 Lf 3 ACTIVE FACILITY TANK ID # s CLOSURE FEE= $294 !TANK # TANKS X $294 = $500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) 2002 2003 2004 2005 2006 2007 $ $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New — $ Installs as of 8/1/07) $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 =$24.00/ FACILITY $ PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # s CLOSURE FEE= $294 !TANK # TANKS X $294 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $294 / FACILITY INSTALLATION PLAN (Plan Check and Const TANK ID # (s) : PLAN CHECK FEE = $784 / FACILITY REPAIR PLAN CHECK TANK ID # (s): $ TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, s ill buckets, tank sumps, misc.) $ PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect.) $ MISCELLANEOUS TRANSFER FEE _ $ 20 $ CONSULTATION FEE . = $ 98/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR $ SAMPLING INSPECTION FEE _ $ 98/ HOUR ALL FEES ARE BASED ON THE $98 HOURLY RATE_ TIME T14AT =.--c �� ,. __ $ � U "iLL BE BILLED I U Ak OFFICE USE ONLY SERVICE REQUEST # I FACILITY ID I AMOUNT RECEIVED CHECK # _ RECEIVED BY I DATE RECEIVED SR EH 23 032 (REVISED 08/3107)