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SAN JOAQUIN COUNTY <br /> • ENVIRONMENTAL HEALTH DEPARTME <br /> 600 East Main Street, Stockton,CA 95202-3 9 <br /> Telephone:(209)468-3420 Far.(209)468-3433 Web: www.sigov.org/eh <br /> FACILITY NAPE41 <br /> FACILITY CONTACT E <br /> CIN Al 42"&u <br /> F ILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> H V9 �► 8/0 - <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICAN ILLI G NAME APPLI T CONTACT NAME <br /> APPLI AN ING ADDR SS APPLICANT PHONE#WITH AREA CODE <br /> o'1S3r d% � /- '/. <br /> CITY STATE //,�ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> '71�F Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2002 2003 2004 2005 2006 2007 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008 8 New <br /> Installs as of 8/1/07) $ <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 /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$294/TANK #TANKS X$294= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK Io#(a): TEMPORARY CLOSURE FEE_$294/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <br /> TANK ID#(s): PLAN CHECK FEE_$784/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) $,r�/} <br /> PIPING REPAIR FEE =$294/FACILITY use for piping,under-dispenser containment,act) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $98/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR $ <br /> SAMPLING INSPECTION FEE _ $98/HOUR $ <br /> ALL FEES ARE BASED ON THE$99 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED I CHECK# I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 D32(REVISED 0913/071 <br />