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a <br /> SAN JOAQUIN COUN'T'Y <br /> ENVIRONMENTAL HEALTH DFPARTMENIT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)463-3433 Web:wv w_sj�n�,orF?/elid <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY A RESS SITE PHONE#WITH AREA CODE <br /> .,z 6 aG- 3 SS/ <br /> CITY STATE I ZIPCODE #OF TANKS AT SITE <br /> c <br /> .s _x CA / ��6 L <br /> APPLICANT BILLING NAME APPLICANT C//ONTA/CTT NAME <br /> C <br /> '41. _lC /T <br /> AP151LICANT MAILINGYADDRESS I APPLICANT PHONE#WITH AREA CODE <br /> Yoo S4-7 I (a;:�/ -?6 - 7 <br /> CITY STATE ZIP CODE7 CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installatlon Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2002-2007) 2003 2004 2005 2006 2007 2008 <br /> 5550 FEE INCLUDES FACILITY FEE+1 TANK(2008) <br /> $125 PER TANK AFTF_R FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCI­IARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$24.00/FACILITY <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)., TEMPORARY CLOSURE FEE=$294/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK 10#(s)' PLAN CHECK FEE_$784/FACILITY $ <br /> REPAIR PLAN CHECK <br /> 'TANK ID#(S) <br /> TANK RE-rROFIT REPAIR FEE =$294 /FACILITY (use for monitoring equipment,cold starts.EVR upgrades, 9 <br /> sill buckets.eum s,mist. <br /> PIPING REPAIR FEE _$294/FACILITY (use for fin ,under-dls enser containment,ect,) $ <br /> MISCELLANEOUS <br /> TRANSFER FkE $20 $ <br /> CONSULTATION FEE _ $g8/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR $ <br /> SAMPLING INSPECTION FEE = S SB/HOUR $ <br /> ALL FEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL 13E BILLED TO APPLICANT, <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED CHECK I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 Ogg(REVISED 12/31/07) <br /> 9G�zG 39Vd -17IH >cnHO C7,SECGCT99 ZT :ZZ 830z/Z0/SG <br />