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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 Easl Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Far: (209)468-3433 Web:www.sigoy.org/chd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Raleys Dawn Dirckson <br /> FACILITY ADDRESS SITE PHONE N WITH AREA CODE <br /> 4219 Morada Lane, Stockton CA 95212 209-9 6-9300 <br /> CITY STATE ZIP CODE N OF TANKS AT SITE <br /> Stockton CA 95212 <br /> 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Able Maintenance Inc MartyWeithman <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE N WITH AREA CODE <br /> 680 Quinn Ave. 408- 213-6038 <br /> CITY STATE 21P CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC N <br /> San Jose CA 95112 0 <br /> 5250610 <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2003-2008) 2004 2005 2006 2007 2008 2009 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009) <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 ACUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(a): CLOSURE FEE=$315/TANK N TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID N(s); TEMPORARY CLOSURE FEE_$315/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <br /> TANK IDN(s): PLAN CHECK FEE_$840!FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrade,, $ 456 <br /> s ill buckets,sum s misc. <br /> PIPING REPAIR FEE _$315/FACILITY use for in ,under-dls nser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $2D $ <br /> CONSULTATION FEE _ $ 1051 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $ 105/HOUR $ <br /> SAMPLING INSPECTION FEE = $105/HOUR $ <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST#_ FACILITY ID AMOUNT RECEIVED CHECK N RECEIVED BY DATE RECEIVED <br /> SR <br /> EN 23 032(REVISED 02/23/09) <br />