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05/22/2009 14: 43 6613933523 CHUCK HILL PAGE 04117 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL 14EAL Cl-[DEPART STT NT <br /> 600 East Main Strcct.Stockton,CA 95202-3029 <br /> Telephone:(209)465-3420 Fax:(209)463-3433 Web:wwtiv.sixov.org/citd <br /> FACILITY <br /> /NAME FA—CILITY CONTACT NAME <br /> O 44/` 4'h <br /> FACILITY AD ESS SITE PHONE#WITH AREA CODE <br /> LI <br /> CITY v ol STATEZIP CODE ax OF TANKS AT SITE <br /> .s�G/to 11 CA 9sZ� <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> �t'06<s' Closure Installatlon Repalr etroilt ����Qfy U <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2.008 j 2009 <br /> $500 FEE INCLUDES FACILITY FEF_+1 TANK(2004-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2009) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE:515/TANK <br /> STATC SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACII-ITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure In Place <br /> TANK ID#(s): CLOSURE FEE_,5315/TANK A TANKS X$315= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK Ib#(a): I TEMPORARY CLOSURE FEE=$315/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Chock and Construction Ins ectlons <br /> TANK ID#(s): I PLAN CHECK FEE_$810/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEF_ =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgradaS, <br /> spill buckets sums mise. <br /> PIPING REPAIR FEE Q$315/FACILITY use for plping,under-dispenser containment ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE = 5 20 <br /> CONSULTATION FEE - S 105/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $105/HOUR <br /> SAMPLING INSPECTION FEE _ $ 105/HOUR <br /> ALL FEES ARE BASED ON THE 5105 HOURLY RATE. Trane THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY 10 AMOUNT RECEIVED I CHECK 0 RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 09120109) <br />