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SAN JOAQUIN COUNTY _ \ ENVIRONMENTAL HEALTH DEPARTMET %W 600 East Main Street, Stockton, CA 95202-3'b r Telephone: (209) 468-3420 Fax: (209) 468-3433 Weh: www.sjgov.org/ehd FACILITY NAME FACILITY CONTACT NAME TANK ID # (s) : APPLI ANT CONTACT NAME FACILITY ADDRESS SITE PHONE # WITH AREA CODE } ` U(C 2a 6o.3- 33`iti CITY STATE ZIP CODE # OF TANKS AT SITE —5-aCq CA q53-7t�-N t Z APPLICANT BILLING NAME Removal or Permitted Closure in Place TANK ID # (s) : APPLI ANT CONTACT NAME W104 Rnorn rvicr-d nC. < ')n L4 n)-\ APPLICANT MAILING ADDRESS 2007 2008 APPLICANT PHONE # WITH AREA CODE Z3n5 P-17�,cS izx-jtxc) c $500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) (ZLQ) 07l5b CITY $ STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # I ( nr- $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) CA %? OL -j j Closure Installation Repair Retrofit ACTIVE FACILITY Removal or Permitted Closure in Place TANK ID # (s) : $ 2003 2004 2005 2006 2007 2008 TANK ID # (s) : TEMPORARY CLOSURE FEE = $2941 FACILITY $500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) 4/ $ SAMPLING INSPECTION FEE = HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) $ $125 PER TANK AFTER FIRST TANK,L'� -s'" ..L" $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $15 / TANK 'Ly STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY $ PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s) : $ Z TANK ID # (a): CLOSURE FEE = $294 / TANK # TANKS X $294 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $2941 FACILITY TANK ID # (s) : I PLAN CHECK FEE = $784 / FACILITY I Y .-&;I— REPAIR PLAN CHECK FACILITY ID TANK ID # (s) : $ TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $ spill buckets, sumps, misc. r $ 31. CONSULTATION FEE _ $-08/ HOUR I� Yt j-otA tjJ e)o $. PIPING REPAIR FEE _ $294 /FACILITY use for piping, under -dispenser containment, ect. $ MISCELLANEOUS FACILITY ID I AMOUNT RECEIVED $ TRANSFER FEE _ $ 20 RECEIVED BY pp y� /J i L h'-w%A,} r $ 31. CONSULTATION FEE _ $-08/ HOUR I� Yt j-otA tjJ e)o IV $ UNAUTHORIZED RELEASE EVALUATION FEE = $98/ HOUR 4/ $ SAMPLING INSPECTION FEE = HOUR ALL FEES ARE BASED ON THE $98 HOURLY RATE. TIME THAT EXcEED8 rets YAIu WILL et CIutU TV At OFFICF IISF ONI Y SERVICE REQUEST#. FACILITY ID I AMOUNT RECEIVED CHECK -# RECEIVED BY DATE RECEIVED FH *1 MI /PP VIQPn 19/11 /O91