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• SAN JOAQUIN COUNTY <br /> N/ ENVIRONMENTAL HEALTH DEPARTMENT-A/ <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.o4r chd <br /> FACILITY NAME FAC CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE f WITH AR CODE <br /> 2 e'ra (?-P 1/ —2s <br /> CITY I STATE ZJP CODE f OF TANKS AT SITE <br /> � d CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> r <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE f WIT AREA CODE <br /> 3/ ?y / - z � <br /> CITY tock STATE ZJP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC f <br /> ct qf'?o Closure Installation epair RetroTd <br /> ACTIVE FACILITY <br /> 2003 2004 2005 2006 2007 2008 <br /> E500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(200P) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE_$15!TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=E24.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID f s CLOSURE FEE_$294/TANK f TANKS X$294= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID f(a): TEMPORARY CLOSURE FEE_$294/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID f(a): PLAN CHECK FEE_$784/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK 10 f(a): <br /> TANK RETROFIT REPAIR FEE $294/FACIL (use for monitoring equipment,cold starts,EVR upgrades, <br /> soil buckets,sumps,misc. <br /> $ <br /> PIPING REPAIR FEE _$294/FACILITY use for piping,under-dispenser Containment,act. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE = E 98/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR <br /> SAMPLING INSPECTION FEE = E 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# I FACIUTYID I AMOUNT RECEIVED I CHECK# I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 72131107( <br />