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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTII DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone.(209)468-3420 Fax:(209)468-3433 Web. w",s ehd <br /> �FAC�IUTYNAME 1 FACILITY CONTACT NAME <br /> prL./?u-, 1-1v C' (oyl t IlQvY1C�5 <br /> FACILITY ADDRESS ���� }} SITE PHONE#WITH AREA COVE <br /> 14b oo S. A lir I/ <br /> r4 VG <br /> CITY ATE ZIP CODE #OF TANKS AT SITE <br /> Y1 CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> s acs P d 1&'h -TI-icr -az <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE jZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> JY� Closure installation Repair Retrofit �se4-u� <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) 2003 2004 2005 2006 2007 2008 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2Dg8) <br /> $1,25 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=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURL�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 ID#(s): PLAN CHECK FEE=$7841 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$294 1 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> s ill buckets,sum s,mist. <br /> PIPING REPAIR FEE _$294/FACILITY use for pi in ,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $98/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $98/HOUR $ <br /> SAMPLING INSPECTION FEE _ $98/HOUR <br /> ALL FEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY- <br /> DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 12137107) <br />