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IV 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.si2ov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />rr yy�� �y p <br />lisp, 'fT 8222 <br />Lisp, <br />avilu 2=s <br />FACILITY ADDRESS <br />SITE PH # WITH AREA CODE <br />2005 <br />4 Z82� <br />CITYI <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />CA <br />IjInZb5 <br />STATE IJ ZIP CODE <br />APPLICANT BILLING NAME <br />TANK ID # (s): <br />APPLICANT CONTACT NAME <br />2002 <br />2003 <br />2004 <br />2005 <br />PLICA''NT^MAILING ADDRESS <br />2007 <br />APPLICANT PHONE # WITH AREA CODE <br />U.1. <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />CITY <br />$ <br />STATE IJ ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />ZClosure <br />Installation Repair Retrofit <br />-ICT <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $2941 TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />$ <br />1 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />$ <br />Installs as of 8/1/07) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE =$15/TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <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 # (a): <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />REPAIR PLAN CHECK <br />ID <br />TANK ID # (a): <br />$ <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY use for monitoring equipment, s ill buckets, tank sumps, misc. <br />$ <br />PIPING REPAIR FEE = $294 / FACILITY use for piping, under -dispenser containment, act. <br />MISCELLANEOUS <br />ID <br />AMOUNT RECEIVED <br />$ <br />TRANSFER FEE _ $ 20 <br />BY <br />DATE RECEIVED <br />$ <br />CONSULTATION FEE = $ 981 HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 98/ HOUR <br />ALL FEES ARE BASED ON THE $96 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST#FACILITY <br />ID <br />AMOUNT RECEIVED <br />CHECK # <br />RECEIVED <br />BY <br />DATE RECEIVED <br />SR <br />cn 23 032 (REVISED ualslur) <br />