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TANK ID # (s�: <br />TANK RETROFITREPAIR FEE = $279 / FACILITY <br />V- &atA[t Lr Tye E t <br />P.IE1Dt =PAIR FEE = $279 / FACILITY (use for piping, under - <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE = $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 931 HOUR <br />pill buckets, tank s <br />containment, ect' <br />SAMPLING INSPECTION FEE = $ 931 HOUR <br />ALL FEES ARE BASED QN THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO <br />OFFICE USE ONLY <br />L <br />I <br />SERVICE REQUEST # FACILITY ID _ AMOUNT RECEIVED CHECKIV RECEIVED BY DATE RECEIVED <br />Sq <br />R I - �� <br />EH 23 032 (REVISED D2122/ 651 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEAL7'Ft DE-PARTNIENT <br />304 East Weber Avenue, 3r° Floor, Stockton, CA 95202-2708 <br />Telephone: (209) <br />468-3420 FrLv (54floor): (209) 468-3433 Web: www.s' ov.orgehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />FACILITY ADDRESS <br />SITE PHONE A WITH AREA CODE <br />GIN <br />STATE ZIP CODE# <br />OF TANKS AT SITE <br />z} ' �Tu&n <br />CA % <br />BILLING NAME <br />APPLICANT CONT NAME <br />r ) <br />Babld� MAILI ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />CITY <br />STArtE <br />ZIP CODE <br />CIRCLE WORK DONE <br />CONTRACTOR ICC # <br />Closure Instailati Rep it etroft <br />ACTIVE FACILITY <br />2000 <br />5500 FEE INCLUDES FACILITY FEE+ 1 TANK <br />2001 <br />zaa2 <br />2003 <br />2004 <br />2005 <br />$125 PER TANK AFTER FIRST TANK <br />_ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE _ $151 TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.001 FACILITY <br />$ <br />ANENTCLOSURE <br />or Permitted Closure in Place <br />pRemoval <br />p # s <br />CLOSURE <br />CLOSURE FEE = $2791 TANK # TANKS X $279 = <br />$RARY <br />eview and Ins ectionsD <br /># (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />$ <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections)I <br />TANK ID # (s) : <br />PLAN CHECK FEE = $744 1 FACILfTY <br />$ <br />j REPAIR PLAN CHECK <br />i <br />TANK ID # (s�: <br />TANK RETROFITREPAIR FEE = $279 / FACILITY <br />V- &atA[t Lr Tye E t <br />P.IE1Dt =PAIR FEE = $279 / FACILITY (use for piping, under - <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE = $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 931 HOUR <br />pill buckets, tank s <br />containment, ect' <br />SAMPLING INSPECTION FEE = $ 931 HOUR <br />ALL FEES ARE BASED QN THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO <br />OFFICE USE ONLY <br />L <br />I <br />SERVICE REQUEST # FACILITY ID _ AMOUNT RECEIVED CHECKIV RECEIVED BY DATE RECEIVED <br />Sq <br />R I - �� <br />EH 23 032 (REVISED D2122/ 651 <br />