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SAN JOAQUIN COUNTY --/ <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3`"Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(5#'floor):(209)468-3433 Web:www.sieov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> COS CO * 656 1/M '5/7iw& <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 395o w 609wjf ZwiF 916 BY9- GYGS <br /> CITY I STATE ZIP CODE 1 #OF TANKS AT SITE <br /> 7Lr4C CA 't <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> c�'a c.E ' Err /,,,c -I-/m 54/'VE <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 30mq /9�E �E S 9/6 8Y 5'- 6Y6S <br /> �. <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> 5gcrgmkAl o c.9 95838 Closure Installation epat Retrofit 5A5.2331-u / <br /> ACTIVE FACILITY <br /> 2000 2001 2002 2003 2004 2005 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=S75/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 5279= <br /> TEMPORARY CLOSURE <br /> Plan Review and ins ions <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Pian 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,spill buckets,hank sumps,mist. <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping,under-dispenser containment,ecl.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $93l 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 THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACIUTYID I AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02122/05) <br />