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• <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPAR'T'MENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org-/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> I <br /> r <br /> FACILITY ADDR SS SITE PHONE#WITH AREA CODE <br /> I qC 0611 ) 1�13cl - �3 / 7 <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> ma n{(,ri�l�. CA <br /> APPLICANT BILLINQ NAME APPLICAKT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY ST TE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> l Closure Installati Re air Retrofit <br /> ACTIVE FACILITY <br /> 2006 2007 2008 2009 2010 2011 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2006-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2011) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$151 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.001 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$3751 TANK #TANKS X$375= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$3751 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ v <br /> TANK ID#(s): PLAN CHECK FEE=$1,0001 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$375 1 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 14,•T <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE=$3751 FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 <br /> CONSULTATION FEE = $ 1251 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE - $1251 HOUR $ <br /> SAMPLING INSPECTION FEE = $1251 HOUR $ <br /> ALL FEES ARE BASED ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 0811!11 by KF) / ``!! <br /> p,:) - ,� pow <br />