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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEP <br /> 600 Telephone.(20 9)468- Street,Main <br /> 3420 Fax (209)468-3 33 Web:www s' ov.or ehd <br /> FACILITY NAME <br /> r=at <br /> FACILITY CONTACT NAME <br /> S- c <br /> FACILITY ADDRESS <br /> SITE PHONE#WITH AREA CpDE <br /> �Sb�7 Com; A V - <br /> CITY <br /> STATE ZIP CODE <br /> c' CA #OF TANKS AT SITE <br /> APPLICANT BILLING NAME <br /> APPLICANT CONTACT NAME <br /> APPLICANT MA NG ADDRESS <br /> APPLICANT PHONE#WITH ARE c <br /> 1 S�' ` �, Fes.«� r ODE <br /> CITY STATE ZIP CODE ?4 -`- C)�/9 <br /> CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> ACTIVE FACILITY Closure Installatio Re ai Retrofit E <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007-2008) 2007 2008 2009 2010 2011 2012 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009-2012) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.001 FACILITY <br /> PERMANENT CLOSURE $ <br /> Removal or Permitted Closure in Place <br /> TANK ID# s <br /> TEMPORARY CLOSURE CLOSURE FEE_$3751 TANK #TANKS X$375= $ <br /> Plan Review and Ins ections <br /> TANK ID#{s): TEMPORARY CLOSURE FEE_$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Pian Check and Construction Ins ections <br /> TANK ID#(s): $ <br /> PLAN CHECK FEE_$1000/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK RETROFIT REPAIR FEE =$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ ��s <br /> s ill buckets, <br /> sumps,misc. <br /> PIPING REPAIR FEE _$375 1 FACILITY use for i in ,under-di s enser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE <br /> CONSULTATION FEE _ $125/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $125!HOUR $ <br /> SAMPLING INSPECTION FEE _ $ 125/HOUR $ <br /> ALL FEES ARE BASED ON THE Sl26 HOURLY RATE. TIMETHgT E>iCEEDIS FEES PAID WILL BE BILLED TO APPLICANT. $ <br /> rorAL annouNr aur< <br /> OFFICE USE ONLY $j <br /> SERVICE REOW—T# 1 FACILITY ID I AMOUNT RECEIVED <br /> CHECK I RECEIVED Ry IDATE RECEIVED <br /> EH 23 032(REVISED 04113112 by KF) <br />