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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, Yd Floor,StOCkton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(S`"floor):(209)468-3433 Web: wN w� .Dov ore/el?d <br /> FACILITY NAME <br /> f FACILITY CONTACT NAME <br /> 5 <br /> FACILITY ADDRESS <br /> PHONEY#4001 AREA CODE <br /> CITY C�� !5 Q3©6 <br /> STATE ZIP GODE <br /> ��C ��� #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME <br /> �-Eve S APPLICANT CONTACT NAME <br /> 5ee� — p <br /> APPLICANT MAILING ADDRESS 4L wt <br /> APPLICANT HONE#WITH AREA CODE <br /> Ave, <br /> CITY STATE <br /> ZIP CODE CIRCLE WORK TO BE DONE <br /> SRL �� dt CONTRACTORPCC.# <br /> L/�- 1 S r 14- Closure Installation e air Retrofit — <br /> ACTIVE FACILITY L <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK 2002 2003 2004 2005 2006 <br /> $125 PER TANK AFTER FIRST TANK 2007 <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.001 FACILITY <br /> $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure In Place <br /> TANK ID# s : <br /> TEMPORARY CLOSURE CLOSURE FEE=$285 L TANK #TANKS X$285= $ <br /> Plan Review and Ins ections <br /> TEMPORARY CLOSURE FEE_$2851 FACILITY <br /> INSTALLATION FLAN CHECK <br /> Plan Check and Construction Ins ections <br /> TANK ID#(s) <br /> PLAN CHECK FEE_$760/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> TANK RETROFIT REPAIR FEE =$285 1 FACILITY use for monitoring a ui ment,spill buckets,tank sum s,misc. <br /> PfPING REPAIR FEE _$285 1 FACILITY use for pipin ,under-dis enser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE A $20 $ <br /> CONSULTATION FEE _ $95/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $951 HOUR $ <br /> SAMPLING INSPECTION FEE = $95/HOUR $ <br /> ALL FEES ARE BASED ON THE$95 HOURLY RATE. 1 ROL THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID <br /> AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01/29107) <br />