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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPAR7V <br /> 04 East Weber Avenue,3"Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(5"floor):(209)468-3433 Web:mma-silzov.0reebi <br /> FACILITY NAME !- FACILITY CONTACT NAME <br /> 1�GC1 4cf- IC- 12-o," cj� <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> ,,`e 'P?3- $7cc <br /> CITY f! STATE ZIP CODE #OF TANKS AT SITE <br /> �ocK7o� CA C r ��� <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> lbac ( ro �� IC(ik� <br /> A EI t� ah <br /> APPLICT AILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> is v"_ CII, zvs �� <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> c;4- c Ear L}� S Closure Installation pair etrotit <br /> ACTIVE FACILITY <br /> 20 2005 2006 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 2002 03 2004 2007 <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANKSURCHARGE=$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 /> TANKID# s CLOSURE FEE_$285/TANK #TANKS X$285= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$285/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$760/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$285/FACILITY Luse for monitoring equipment,s ill buckets,tank sumps,misc. $ <br /> PIPING REPAIR FEE =$285/FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $95/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $95/HOUR $ <br /> SAMPLING INSPECTION FEE RU <br /> $95/HOUR $ - <br /> ALL FEES ARE BASED ON THE$95 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> [SERVICE REQUESTA FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 01/29/07) <br />