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. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3id Floor,Stockton,CA 95202-2708 <br /> Telephone.(209)468-3420 Fax(5 ,/loor):(209)468-3433 Web:www.sigov.org/ehd <br /> FACILITY NAME FAC ITY CONTACT NAME <br /> s4- + E S to 0 U Z � S+v-.t-e 1m ave <br /> FACILITY ADDRESS I SITE PHONE#WITH AREA CODE <br /> q ( 209) iois <br /> CRy STATE ZIP C(/O]jDE� i #OF TANKS AT SITE <br /> ( � CA 7521 Z <br /> APPLICANT BILLING NAME OCIRCLE <br /> %LDION <br /> Fast + 'F_aS (00 APPLICANT MAILING ADDRESS CODE <br /> d cbl� Nr Rw R 9 CITY STATE ZIP CODECONTRACTORICC# <br /> 1�21 — Closure Installafit <br /> ACTIVE FACILITY <br /> 2000 2001 2002 zoos 2004 zoos <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$151 TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.001 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE_$2791 TANK #TANKS X$279= <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(a): PLAN CHECK FEE=$7441 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> $ <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,spill buckets,tank sumps,misc.)'(fl <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $931 HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $931 HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $931 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 AMOUNTRECENED CHECK# RECENED BY DATE RECENED <br /> SR <br /> EH 23 032(REVISED 02/22105) <br />