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SAN JOA U`fN COUNTY <br /> LINTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Stree�_Stock-ton,CA 95202-3029 <br /> Telephone_(209)46$-3420 Fax.(209)469-j433 Web.www.siiroy.orelehii <br /> FACILITY NAME <br /> f FACILITY CONTACT NAME <br /> FACILITY AD SS <br /> A AIA <br /> SITE PHONE#WITN <br /> CITY c <br /> STATE. ZIP CODE #OF 7-ANKS AT SITE <br /> CA. <br /> • APPLIcaNT sltuuG NAME <br /> APPLICANT CONTACT NAME <br /> APPLIC <br /> All'TMAILINGADDRESS . <br /> APPLICANT PHONE#WITH AREA CODS <br /> CITY � <br /> STATE_... ..IJP CODE-- CIRCLE WORK TO BE ONE <br /> - CONTRACTOR lCC# <br /> Closure Installation .R air'Retrofit <br /> ACTIVE FACELIi Y - <br /> $500 FEE JNCLUbES FACILITY FEE+1 TANK(2b03-2008) 2004 . 2005 2006 2007- 2008, . 2009 <br /> 4550FEE INCLUDES FACILITY FEE 1?ANK(2009) <br /> .$1`25 PER TANK AFTER FIRST TANK <br /> All <br /> PENALTY ASSESSED <br /> TANK SURCI' RGE=$Is I TANK <br /> STATE SURCHARGE FOR FACILITIES NOTALREAD'Y owl <br /> NVENTORY IN A CUPA PROGRAM=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> STANK OD# s : #TANKS X$315= f <br /> TEiIEfPORARY CLOSURE CLOSURE FEE=$315/TANK <br /> _. evietvand4nspet*ons)- <br /> . a <br /> TANK ID#(s) <br /> TE1KlPORARY CLOSURE FEE $315 f FACILITY $ <br /> INSTAL{g7iON PLAN CHECK. <br /> tan Check and Construcaan Ins e-,:-. <br /> TANK ID#(s).: <br /> PLAN.CHECK FEF=$840 I FACILITY <br /> Rl~PAIR PLAN CHECK. . <br /> TANK4D#(s} <br /> TMK ' <br /> - RETROFIT REPAIR FEl= _$3 i5 7 FACILITY (use for m4nitnrOg equipment;eold�slarts;EVR iipgiades, <br /> `PIPING. = . <br /> buckets,:S m ., <br /> . . $3T5f FACILITY . . .• .. .. <br /> REPAIR FEE .:.i � - - <br /> use fnr nder-di <br /> in us enser containmeii,ecL <br /> MISCELLANEOUS <br /> `TRANSFER FEE _ $2D. <br /> -CONSULTATION FEE <br /> _ $1Q51HOUR _ $ ° <br /> -IJNAV HORLZED RELEASE EVALUATION FEE - C <br /> ` $105fHOUR- $ <br /> _SA.MPLING'INSPECTIQMJ $?Q5/HOUR <br /> SES ARE BASED ON THE$905 HOURLYRATE <br /> TIME THAT EXCEEDS $ <br /> FEES PAID WILL BE BILI-EDTOAPPLICANT. <br /> -OPACE.USE ONLY BIL <br /> SERVICE R1 pU�ST# FAclt Irr tD ' <br /> :. AmouNTRECEfVEO RECEIVED BY <br /> SR.- CHECK# BATE RECE]VE D <br /> EH 23 032(REVISED 07123109) <br />