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• SAN JOAQUIN COUN'rY • <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3"I Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (5ei f7aa): (209) 468-3433 Web: www.sjgov.oru/chd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />der /07/ <br />2000 <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />�(o L4C/C C.ree--_L Lvz_ <br />20cr �i �( - 3Zl3 <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />CA CA <br />9 SZ r <br />-7 (-j S I L 6 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />C2i/q 1671 010 <br />2000 <br />APPLICANT MAILING AD KESS <br />APPLICANT PHONE # WITH AREA CODE <br />2003 <br />2004 <br />CITY <br />STATE <br />ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />[=02 <br />Closure Installation pai Retrofit <br />-7 (-j S I L 6 <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $279 / TANK <br />2000 <br />TEMPORARYCLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />2003 <br />2004 <br />2005 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />[=02 <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <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 />CLOSURE FEE = $279 / TANK <br /># TANKS X $279 = <br />TEMPORARYCLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />ALLATION PLAN CHECK <br />TANK ID # (s) : I PLAN CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK <br />I FACILITY ID <br />TANK ID# (s): <br />I CHECK # <br />TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment, s ill buckets, lank sumps. mise.) <br />DATE RECEIVED <br />PIPING REPAIR FEE = $279 / FACILITY use for piping, under -dispenser containment, eel. <br />MISCELLANEOUS <br />I FACILITY ID <br />AMOUNT RECEIVED <br />I CHECK # <br />TRANSFER FEE _ $ 20 <br />DATE RECEIVED <br />SR <br />CONSULTATION FEE _ $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME IHAI EEUEtUJ rtts YAIU WILL BE naLtu TO <br />OFFICF USE ONLY <br />SERVICE REQUEST# <br />I FACILITY ID <br />AMOUNT RECEIVED <br />I CHECK # <br />I RECEIVED BY <br />DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 02/22/05) <br />