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• SAN JOAQUIN COUNTY • <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone. (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.org/ehd <br />FACILITY NAME <br />0 aST,-I-JC <br />FACILITY CONTACT NAME <br />2 / <br />"' i� L <br />r,J <br />FACILITY ADDRESS <br />Di9N/£L T lJ�/z <br />SITE PHONE # WITH AREA CODE <br />1S3_3 <br />1,✓ d5t- 5'7. <br />209 2_c5 �/ <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />S oClC71 <br />CA <br />9 5-2--e ' <br />WORK TO BE DONE CONTRACTOR ICC # <br />APPLICANT BILLING NAME <br />0 aST,-I-JC <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2005) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$125 PER TANK AFTER FIRST TANK <br />APPLICANT CONTACT NAME <br />%R /.JG <br />rJcLL <br />S&c� <br />Di9N/£L T lJ�/z <br />APPLICANT MAILING ADDRESS <br />$ <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />APPLICANT PHONE # WITH AREA CODE <br />,3-2-0/ Lo <br />i,Fij✓/iF <br />3&V <br />gq -S ©/ 9 <br />CITY <br />STATE <br />ZIP CODECIRCLE <br />WORK TO BE DONE CONTRACTOR ICC # <br />Closure Installation Re air Retrofit <br />ACTIVE FACILITY <br />0 aST,-I-JC <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2005) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$125 PER TANK AFTER FIRST TANK <br />2008 <br />2009 <br />2010 <br />2011 <br />2012 <br />2013 <br />$ <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE =$15/TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY <br />$ <br />PERMANENT CLOSURE p7QVAL. <br />Removal or Permitted Closure in Place <br />0 aST,-I-JC <br />TANK ID # (s): <br />p <br />CLOSURE FEE = $375 / TANK Q # TANKS X $375 = <br />TEMPORARYCLOSURE <br />$ <br />Plan Review and Inspections) <br />$ <br />TANK ID # (a): <br />$ <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />9 <br />REPAIR PLAN CHECK <br />TANK ID # (a): <br />$ <br />TANK RETROFIT REPAIR FEE _ $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />—spill buckets, sums misc. <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, act. <br />$ <br />MISCELLANEOUS <br />ALL • EE•• ARE —2-5---- <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />ON <br />$ <br />o o,.o .,..--I- ...., c. nmc mn, Al....crow r..D rnLL ee eLLLeu I v Anil ANT. <br />TOTAL AMOUNT DUE $ <br />OFFICE USE ONLY <br />