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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTr -_ <br />*w✓ 600 East Main Street, Stockton, CA 9520bW ,9 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />���� T''�Fif.C�t3�(c' '4"� � <br />-{ <br />u�\A, L ..�C'-� c••.�(rG G�V `� i <br />FACI(jL.�ITY ADDRESS(( <br />SITE PHONE # WITH AREA CODE <br />11 \ <br />©9IL <br />C—' C }�i 11Y1 f., 1ClY t'4 V�i)'..y <br />2D�( ii•O.$ - ���i �� <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />APPLICANT PHONE # WITH AREA CODE <br />CA <br />q57 Jlc <br />Z <br />APPLICANT BILLING NAME <br />Removal or Permitted Closure in Place <br />TANK ID # (s) : <br />APPLI ANT CONTACT NAME <br />M-194 n <br />/ :�exvi <br />] <br />2007 <br />JdW L <br />APPLICANT MAILING ADDRESS <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />APPLICANT PHONE # WITH AREA CODE <br />Z -Y,5 rG 1C. <br />� <br />ZC9(53-S,0`68 <br />CITY <br />STATE <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />} (tic <br />� <br />`-15 CL0 <br />Closure Installation Repair Retrofit <br />.. _ <br />ACTIVE FACILITY <br />Removal or Permitted Closure in Place <br />TANK ID # (s) : <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />Plan Review and Inspections) <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 99 / HOUR <br />� <br />$ <br />$98/ H <br />SAMPLING INSPECTION FEE _ OUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />.. _ <br />- <br />.•G <br />TANK PENALTY ASSESSED <br />$ L� <br />$ �r <br />TANK SURCHARGE =$15/TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />$ <br />PERMANENTCLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s) : <br />$ <br />-7/5— <br />Z <br />TANK ID # (s): <br />CLOSURE FEE = $294 / TANK <br /># TANKS X $294 = <br />TEMPORARYCLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ , <br />spill ill buckets, sumps, misc. <br />$ 311 <br />CONSULTATION FEE _ $,88/ HOUR C, y,, g"t ;;;J[vo. <br />$ <br />PIPING REPAIR FEE = $294 / FACILITY use for piping, under -dispenser containment, act. <br />•'ice <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />haS6. { "� �E� C.9;u <br />$ 311 <br />CONSULTATION FEE _ $,88/ HOUR C, y,, g"t ;;;J[vo. <br />)Oa <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 99 / HOUR <br />� <br />$ <br />$98/ H <br />SAMPLING INSPECTION FEE _ OUR <br />ALL FEES ARE BASED ON THE sea HVUKLY KAIE. UMt inAi rxoEcua FEES r�+,u vvi�� o� �,�.., �. •�• •-•--•••-• <br />