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SAN JOAQUIN COUN'Ty <br /> ENti'IRONMENTAL HEALTH DE'PART'MENT <br /> 600 East Main Street, Stockton,Cry.95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.SlPOy.OrElehd <br /> FACILITYFACILITY CONTACT NAME <br /> FACILIS SITE PHONE#WITH AREA CODE <br /> e7u9 <br /> CITY ISTATE ZI CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING AME APPLICANT CONTACT NAME <br /> * C <br /> APPLICANT AILING ADD SS APPLICANT PHONE 0 WITH AREA CODE_ <br /> 7 � /L 6 <br /> CITY STATE ZIP CODE CIRCLE WORK TO DONE CONTRACTOR 1CC# <br /> a ( � Closure Installation epair Retrofit <br /> ACTIVE FACILITY <br /> 2002 2403 2004 2005 2006 2007 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008&New $ <br /> .S`M 15 3S Cf 3;' C7} <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=$24.001 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted G4osure in Place $ <br /> TANK ID# s CLOSURE FEE_$2941 TANK #TANKS X$294= <br /> TEMPORARY CLOSURE <br /> t <br /> n Review and Ins actionsNK ID#(s): TEMPORARY CLOSURE FEE=$294/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Chock and Construction Inspections) $ <br /> PLAN CHECK FEE_$784 1 FACILITY <br /> TANK ID#(s): <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $ <br /> TANK RETROFIT REPAIR FEE _$294 1 FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) $ <br /> PIPING REPAIR FEE _$294 I FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE = S20 $ <br /> CONSULTATION FEE _ $981 HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $981 HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $981 HOUR <br /> ALL FEES ARE BASED ON THE S9$HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> FS <br /> ERVICE <br /> EREQUEST# FACIL�10) AMOUNT RECEIVED CHECK# RECEIVED B77711 <br /> R <br /> EH 23 032(REVISED OB13107) <br />