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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME?�/ 30e'ast Weber Avenue,3rd Floor,Stockton,CA 95202-2708 Telephone:(209)468-3420 Fax(5tb Jloor):(209)468-3433 Web:www.siPov.orgJe FACILITY NAME FACILITY CONTACT NAME omUAl.,, gAr-?UO-L, FACILITY ADDRESS I A SITE PHONE#WITH AREA CODE y l CITY STATE ZIP CODE I #OF TANKS Al SITE (/V-) CA gSIt)j APPLICANT BILLING NAME APPLICANT CONTACT NAME APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# Closure Installation Repair Retrofit ACTIVE FACILITY 2001 2002 2003 2004 2005 2006 $500 FEE INCLUDES FACILITY FEE+1 TANK $125 PER TANK AFTER FIRST TANK Sao 1 T00 S—tdoos-ao moa S-00 $ ? 6540o d TANK PENALTY ASSESSED rob yov o0 oo 6D 96*0 $3 d00 TANK SURCHARGE=$15/TANK $ / S- STATE `S STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY is 7K PERMANENT CLOSURE Removal or Permitted Closure in Place $ TANK ID#(s): CLOSURE FEE=$285/TANK #TANKS X$285= TEMPORARY CLOSURE Plan Review and Inspections) $ TANK ID#(s): TEMPORARY CLOSURE FEE=$285/FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) $ TANK ID#(a): PLAN CHECK FEE=$760/FACILITY REPAIR PLAN CHECK TANK ID#(s): $ TANK RETROFIT REPAIR FEE =$285/FACILITY use for monitoring equipment,spill buckets,tank sumps,misc. PIPING REPAIR FEE _$2851 FACILITY use for piping,under-dispenser containment,act. MISCELLANEOUS $ TRANSFER FEE _ $20 $ CONSULTATION FEE _ $95/HOUR UNAUTHORIZED RELEASE EVALUATION FEE _ $95/HOUR SAMPLING INSPECTION FEE _ $95/HOUR ALL FEES ARE BASED ON THE$95 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED I CHECK# RECEIVED BY DATE RECEIVED SIR I I EH 23 032(REVISED 01/29/07)