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• SAN JOAQUIN COUNTY • <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sieov.org <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />C.heL/q Ll s <br />(.I.Iti I.l..l1-0L(9 <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />3 3 Li <br />( 2 Vet) 0j L(3 - 3 21 2) <br />CITY <br />I STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />'R I P°>` <br />ICA <br />q 5 3 6 (o <br />I I <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />CLOSURE FEE = $2941 TANK <br />(.I.Iti I.l..l1-0L(9 <br />2003 12004 <br />APPLICANT MAILING ADDII—o R <br />APPLICANT PHONE # WITH AREA CODE <br />f <br />__ &k - <br />19'.1 G_ c. kc -r e //- <br />L <br />2007 <br />CITY <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />1—L)Ck:r <br />I I <br />SAMPLING INSPECTION FEE _ $981 HOUR <br />Closure Installation Repair Retrofit <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 _1 _v. <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $2941 TANK <br />2002 <br />2003 12004 <br />TANK ID # (s) : <br />2005 <br />2006 <br />2007 <br />$500 FEE INCLUDES FACILITY FEE+ 1 TANK (2002-2007) <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 98 /HOUR <br />SAMPLING INSPECTION FEE _ $981 HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 _1 _v. <br />$ <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 COPA PROGRAM =$24.00/ FACILITY <br />PERMANENTCLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $2941 TANK <br /># TANKS X $294 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />REPAIR PLAN CHECK <br />I FACILITY ID <br />TANK 10# (a): <br />CHECK# <br />TANK RETROFIT REPAIR FEE _ $294 /FACILITY use for monitoring equipment, spill buckets, tank sumps, mist. <br />DATE RECEIVED <br />PIPING REPAIR FEE = $294 / FACILITY use for piping, under -dispenser containment, act. <br />$ <br />MISCELLANEOUS <br />I FACILITY ID <br />AMOUNT RECEIVED <br />CHECK# <br />TRANSFER FEE _ $ 20 <br />DATE RECEIVED <br />SR <br />CONSULTATION FEE _ $ 98/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 98 /HOUR <br />SAMPLING INSPECTION FEE _ $981 HOUR <br />ALL FEES ARE BASED ON THE $98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST# <br />I FACILITY ID <br />AMOUNT RECEIVED <br />CHECK# <br />I RECEIVED BY <br />DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 0813107) <br />