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• • <br /> SAN AQ COUNTY AMD' ( ))M <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sieov or¢/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 5' <br /> FACILITY A DRE S SITE PHONE#WITH AREA CODE <br /> TMOK IQ � 2-09 1GS� ��i� Qi <br /> CITY STATE ZIP CODE OF TANKS AT TS <br /> ITE <br /> 1�'�T�j� CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS— APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation a air Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007.2008) 2008 2009 2010 2013 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009.2012) $ <br /> 2011 2012 <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$375/TANK #TANKS X$375= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1000/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> s ill buckets,sum s,mist. 7-S- <br /> PIPING REPAIR FEE _$375/FACILITY use for 2iping,under-dispenser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE _ $125/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $125/HOUR $ <br /> SAMPLING INSPECTION FEE _ $125/HOUR $ <br /> ALL FEES ARE BASED ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEE5 PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED I CHECK# I RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 1/16/2013 by KF) <br />