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• SAN JOAQUIN COUNTY • R E C� LLQ NE <br /> LTJ <br /> ENVIRONMENTAL HEALTH DEPARTMENT Ll <br /> 304 East Weber Avenue,3d Floor,Stockton,CA 95202-2708 QQ��(( <br /> Telephone:(209)468-3420 Fax(5'"floor):(209)468-3433 Web:www.s• ov.or ehP 1 3 2006 <br /> FACILITY NAME FACILITY CONTACT NAME ENVIRONMENT HE 11H <br /> C 12 \.- Sir\ � /' .-\& VICES <br /> FACILITY ADDRESS SITE PHONE MITHAREA CODE <br /> I 73 <br /> CITY I I STATE ZIP CODE #OF TANKS AT SITE <br /> Ca 7 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> C)i. 0I � <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> -4 <br /> CITY <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> J Closure Installation epair trofit 1 cc)3 <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 2000 2001 2002 2003 2004 2005 <br /> $125 PER TANK AFTER FIRST TANK <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 $ <br /> PERMANENTCLOSURE - <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY use for monitoring equipment,s ill buckets,tank sumps,mist. <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,ect. 7cr' <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $93/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93l HOUR <br /> SAMPLING INSPECTION FEE _ $93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNTRECEIVEO I CHECK# RECEIVED BY DATERECEIVED <br /> SR <br /> EH 23 032(REVISED 02/22/05) <br />