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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.si o� v.or ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />ovE 'S v L- j 00 <br />ItEITHPOUCd <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />/ o <br />ZO "I -0 -4 -YO <br />CITY <br />STATE <br />ZIP CODE <br />I # OF TANKS AT SITE <br />l21POAJ <br />CA <br />9S"Ifo3 3 <br />I S <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />L-4. ;�- e—TRocEvrr fliff-i4carr <br />ItEITHPOUCd <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />-7W- E . <br />2012 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />?/ <br />I Closure Installatio a airetro <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br />2008 <br />2009 <br />2010 <br />2011 <br />2012 <br />2013 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br /># TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $3751 FACILITY <br />INSTALLATION PLAN <br />TANK ID # <br />PLAN CHECK FEE = $10001 FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TRANSFER FEE _ $ 25 <br />$ <br />TANK RETROFIT REPAIR FEE = $3751 FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, mist. <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />ALL FEES ARE BASED ON THE $125 HOURLY RATE, TIME THAT EXCEEDS FEES PAID WILL eE eILLED I u APPLICAN I. <br />TOTAL AMOUNT DUE — $ 1 <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 1/1612013 by KF) <br />