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SAN JOAQUIN COUNTY f ENVIRONMENTAL HEALTH DEPART&. ; JT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si, of v.otg/ehd FACILITY NAME FACILITY CONTACT NAME ov eS 223 ori C� _` I-%� �C '` (20 FACILITY ADDRESS SITE PHONE # WITH AREA CODE 2007 () N 25.1' -1 7 v ?T_.) -:?— ?CITY CITY STATE I ZIP CODEr # OF TANKS AT SITE PCS CA + / cis -3W 3 fo APPLICANT BILLING NAME APPLICANT CONTACT NAME TF((A 2G� e\ _Ikk �l rr�� APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2007 () N 25.1' -1 7 v ?T_.) -:?— ?CITY CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # PIPING REPAIR FEE = $315 / FACILITY use for piping, nder-dispenser ect.) G"A I 3a1 Closure Installation Repair etrofi ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $315 / TANK 2004 2005 2006 2007 2008 2009 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) containment, J� PIPING REPAIR FEE = $315 / FACILITY use for piping, nder-dispenser ect.) SAMPLING INSPECTION FEE = $105/ HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED TANK SURCHARGE = $151 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 = $315 / TANK # TANKS X $315 TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $315 / FACILITY Plan Check and Construction Inspections) TANK ID # (s) : I PLAN CHECK FEE = $840 / FACILITY REPAIR PLAN CHECK TANK ID # (s) : TRANSFER FEE _ $ 20 TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, spill buckets, sumps, misc. containment, J� PIPING REPAIR FEE = $315 / FACILITY use for piping, nder-dispenser ect.) MISCELLANEOUS TRANSFER FEE _ $ 20 CONSULTATION FEE _ $105/ HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $ 1051 HOUR SAMPLING INSPECTION FEE = $105/ HOUR NUL rCCJ NRC mmo-- OFFICE USE ONLY SERVICE REQUEST # FACILITY ID I AMOUNT RECEIVED I CHECK # RECEIVED BY I DATE RECEIVED SR EH 23 032 (REVISED 03120109)