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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (5 "floor): (209) 468-3433 Web: www.silzov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />ELLDw <br />GNUS Qb L( <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />15-7-S E -PE5co.aE2p W4 L( <br />zo9 533 - , rt, I a <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />-reA <br />CA <br />953oW <br />ZIP CODE <br />APPLICANT BILLING NAME <br />TANK ID # (s): <br />APPLICANT CONTACT NAME <br />SCG17 GOV Ey' <br />2001 <br />S ct5ifl L.O L/ELj <br />APPLICANT MAILING ADDRESS <br />2004 1 <br />APPLICANT PHONE # WITH AREA CODE <br />egI'l0 r+ISS1D/'i <br />guln,s'r6 <br />951 5 912 - 5110 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />e/VER.Si OE <br />GAj <br />99S0ci <br />Closure Installation Repair Retrofit <br />sasatii#lLo <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $279 / TANK <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 1 <br />2005 <br />$5110 FEE INCLUDES FACILITY FEE + 1 TANK <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 /HOUR <br />SAMPLING INSPECTION FEE _ $ 931 HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE _ $15 /TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM =$24.00/ FACILITY <br />PERMANENTCLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $279 / TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK IDS (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />INSTALLATION PLAN CHECK <br />FACILITY ID <br />Plan Check and Construclion Inspections) <br />I CHECK # <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring a ui ment, spill buckets, tank sumps, misc. <br />$ 014 <br />PIPING REPAIR FEE _ $279 /FACILITY use for piping,under-dis nser containment, ect. <br />TANK ID # (s) : <br />PLAN CHECK FEE _ $7441 FACILITY <br />REPAIR PLAN CHECK <br />FACILITY ID <br />TANK ID# (s): <br />I CHECK # <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring a ui ment, spill buckets, tank sumps, misc. <br />$ 014 <br />PIPING REPAIR FEE _ $279 /FACILITY use for piping,under-dis nser containment, ect. <br />MISCELLANEOUS <br />FACILITY ID <br />I AMOUNT RECEIVED <br />I CHECK # <br />TRANSFER FEE _ $ 20 <br />DATE RECEIVED <br />SR <br />CONSULTATION FEE _ $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 /HOUR <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# <br />FACILITY ID <br />I AMOUNT RECEIVED <br />I CHECK # <br />I RECEIVED BY <br />DATE RECEIVED <br />SR <br />EH 23 032 )REVISED 07122/05) <br />