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SAN JOAQUIN COUNTY <br /> MRONMENTAL HEALTH DEPARTMENT <br /> 304 EasMeber Avenue,3rd Floor,Stockton,CA 95202-2711 <br /> Telephone:(209)468-3420 Fax(Pfloor):(209)468-3433 Web:www.sieov.ore/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 1 71.9 <br /> FACILITY ADDR§RP I SITE PHONE#WITH AREA CODE <br /> 3caa_ 009 4(0l- <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> }„ CA -Cf S';IOII3 <br /> APPLICANT BILLING NAME APPLICANT CONkVinTHAREA <br /> APPLICANT MAILING ADDRESS APPLICANT PHODE -CITY STATE ZIP CODE CIRCLE WORKCONTRACTOR ICC#sw� Closure Installatio <br /> ACTIVE FACILITY <br /> 2000 2001 2002 2003 2004 2005 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK <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 A CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID III s <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,s ill buckets,tank sumps,mist. $ <br /> PIPING REPAIR FEE =$279/FACILITY use for'piping,under-dispenser containment,ed. $ <br /> MISCELLANEOUS - <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR $ <br /> SAMPLING INSPECTION FEE = $93/HOUR $ <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK# RECEIVEDBY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02/22/05) <br />