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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENI <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siaov.or <br /> W <br /> gFACILITYACT NAMEng <br /> r ITH AREA CODE <br /> e_ 29'9 �9#OF TANKS AT SITE <br /> - <br /> APPLICANT BILLING NAME I /�/ _ APPLICANT CONTACT NAME <br /> l/.l�cW�S'e-('` �'� �Ef AA.eTS 1'LLLS T /'� UgaQk -`— <br /> APPLICANT MAILING ADDRESS ^ APPLICANT P�HO(NE#W-'7RH AR/EA CODE <br /> CIO 00 �vJ GO Vl- 1'� 2 2-GO ( 6(A1 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> bCA-V1fkc_n_ 9t{.506 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2003-2008) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK $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_$315/TANK #TANKS X$315= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$315/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plen Check and Construction Inspections) $ <br /> TANK ID#(s): PLAN CHECK FEE=$840/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$3151 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> $ <br /> PIPING REPAIR FEE _$315/FACILITY use for i i ,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $105/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $105/HOUR $ <br /> SAMPLING INSPECTION FEE _ $1051 HOUR <br /> ALL FEES ARE BASED ON THE f106 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL Be BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICEREQUEST# I FACILITY ID AMOUNT RECENED I CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01123108) <br />