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SAN JOAQUIN COUNTY a <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orgleb <br />FACILITY NAME <br />APPLICA ONTACT NAME <br />FACILITY CONTACT NAME <br />IV <br />2004 <br />s e MAr <br />m <br />FA I ITY ADDRESS <br />X35 W ra <br />SITE PHONft1WITH AREA CODE <br />a"a A Hiqhwo <br />99 <br />a <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />CA <br />-t <br />95dot� <br />APPLICANT BILLING NAME <br />APPLICA ONTACT NAME <br />6141 <br />IV <br />2004 <br />s e MAr <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />X35 W ra <br />w/ aby-1W-6337 <br />CITY <br />STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />a.� Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID# (s): <br />CLOSURE FEE=$315/TANK <br />2 003 <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />_tri <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 105/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE =$15/TANK <br />$ <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): <br />CLOSURE FEE=$315/TANK <br /># TANKS X$315= <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : - <br />TEMPORARY CLOSURE FEE = $315 / FACILITY <br />PLAN <br />TANK ID # <br />INI.\�[N71S�7w•y�� <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, misc. <br />-PIPING-REPAIR FEE- - CILITY --- - - - - use for piping, under -dispenser containment, ect.) <br />_tri <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 105/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 105/ HOUR <br />ALL rets Ant bASEU UN [HE *lUC HUUHLT HALE. IIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED I CHECK# RECEIVED BY I DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 7/18/08) <br />