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From: 11/03/2008 15:33 Avo-0N�033 <br /> RECEIVED <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTML NOV 4 2008 <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sie_ov`o o/ehd SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> FACILITY NAME FACILIT2"11 <br /> ME <br /> r <br /> r � i <br /> FACILITY ADDRESS' ) ��)) n SII E^PHEA CODE <br /> 5. �SLLc 47+1 C��s)'a Raa� /"" �f �-9CITY STATE ZIP COD #OF TANKS AT SITE <br /> CA IC75 2— <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> L- � �[-p u\ vL ut v�'t�� <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE# ITH AREA CODE <br /> 18632r E, lir-ppe <br /> 9zz9 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC N <br /> V, c �"{S;1_36 Closure Installation Repair Retrofit S1S�t97 t v( <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE*1 TANK(2002-2007) 20031 2004 2005 2006 2007 2008 <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2008) <br /> $125 PER TANK AFTER FIRST TANK b $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ r <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$315/TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins actions <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$315/FACILITY $ <br /> INSTALLATION PLAN CHECK El J'',1(V'liY/y'1,',GA�./ <br /> Plan Cheek and Construction Ins ections /may <br /> TANK ID#(a): PLAN CHECK FEE=$840/FACILITY $ I/ <br /> REPAIR PLAN CHECK UJA <br /> TANK 0X(s): <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment.cold starts, EVR upgrades, $ <br /> ill buckets,sumps.misc- <br /> PIPING REPAIR FEE _$315/FACILITY use for piping,undw-dis anser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE = S 105/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 105/HOUR $ <br /> SAMPLING INSPECTION FEE _ $1051 HOUR $ <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br />