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SAN JOAQUIN COUNTY `11110 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sieov.org/ehd <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />S L,l to 1/ S; <br />a- <br />Gcts r <br />khvjI n <br />S <br />FAC 1 ADDRESS <br />ZIP CODE <br />SITE PHONE # WITH AREA <br />CODE <br />`"-++ W , <br />+- dLv-� ill <br />Za4 <br />lS�g <br />CITY <br />I STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />CA <br />"2 O <br />2 - <br />APPLICANT BILLING NAME <br />APPLICANT <br />APPLICANT CONTACT NAME <br />0, i <br />S L,l to 1/ S; <br />—APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />rd $O i3er vY►O Cir. <br />`�/Z 467 <br />CITY STATE <br />ZIP CODE <br />LE WORK TO BE DONE <br />CONTRACTOR ICC # <br />PIPING REPAIR FEE _ $375 I FACILITY use for piping,under-dispenser containment, act.) <br />Closure stallation Re air Retrofit <br />ACTIVE FACILITY <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />2008 <br />2009 <br />2010 <br />2011 <br />2012 <br />2013 <br />$ <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) <br />PIPING REPAIR FEE _ $375 I FACILITY use for piping,under-dispenser containment, act.) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE _ $15 /TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =§35.001 FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br /># TANKS X $375 = <br />TEMPORARYCLOSURE <br />Plan Review and Inspections) <br />5-0-2A.4,7_ <br />TANK ID # (s) : J d UO '� T ( <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />TANK ID # (a): <br />PLAN CHECK FEE = $1000 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />TANK RETROFIT REPAIR FEE _ $375 /FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, misc. <br />$ <br />PIPING REPAIR FEE _ $375 I FACILITY use for piping,under-dispenser containment, act.) <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 1251 HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />$ <br />ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE I $ <br />vn cs w. Irtwiacu inwm's vy nr) <br />