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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Telephone:(209)468- Street, <br /> 3420 Fax (209)4683 33 Web? <br /> FACILITY NAME U ww .s I 99Y-.or ehd <br /> FACILITY CONTACT NAME <br /> FACILITY ADDRESS � �^ - 5 b j <br /> SITE PHONE#WITH AREA CODE <br /> STATEZ <br /> �7 7JP CODE #OF TANKS AT SITE <br /> APPLICANT BILLING NAME <br /> APPLICANT CONTACT NAME <br /> APPLICAN MAILING ADDRESS <br /> ��� � f .n APP LIGANT PHONE#WITH AREA CODE <br /> i� �� 970 -- 3� <br /> CITY STATE Z1P CODE <br /> CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> 9t- III Closure Installation Rep ' Retrofi 37U 772 T <br /> ACTIVE FACfLITY - / <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) 2003 2004 2005 2006 2007 200$ <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) <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 Closure in Place <br /> TANK ID# s : <br /> TEMPORARY CLOSURE CLOSURE FEE=$294/TANK #TANKS X$294= $ <br /> Plan Review and InsDi <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$294/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Cheek and Construction Ins actions <br /> TANK ID#(s): PLAN CHECK FEE=$784 1 FACILITY $ <br /> rARCHECK <br /> T REPAIR FEE _$2941 FACILITY (use for monitorin $ <br /> g equlpmenl,cold EVR upgrades, <br /> sum s,mists FEE _$294 1 FACILITY use for i Ing,under-dis Denser containment,eot. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $981 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $981 HOUR $ <br /> SAMPLING INSPECTION FEE = r.981 HOUR $ <br /> ALL FEES ARE HASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE 13ILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 12131107) <br />