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SAN JOAQUIN COUNTY 1..0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Te%phone:(209)468-3420 Fax:(209)468-3433 Web:w .sieov.orp,/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> r' o <br /> FAC L ADDRESS SITE PH NE#WITH AREA CODE <br /> 5C9�6 6 1 C1 C "4v $ /wo <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APP CANT BILLING NAME APPLICANT CONTACT NAME <br /> Ve 6n I' W in SC ave <br /> APPLICANT AILING DRESS 4 1 APPLICANT PHONE WITH AREA CODE <br /> v 0& —t.2&1 <br /> CITY STATE LP CODE CIRCLE WORK TO BE DONE CONYRACTORICC# <br /> /.�. Closure Installatio Repair R trofi[ <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2005-2007) 2005 2006 2007 2006 2009 2010 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2010) <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=$49.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$366/TANK #TANKS X$366= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$366/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$976/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$366/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> ill buckets,sumps,misc.)./� <br /> PIPING REPAIR FEE _$366/FACILITY use for piping,under-dispenser Containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $122/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $122/HOUR $ <br /> SAMPLING INSPECTION FEE = $122/HOUR $ <br /> ALL FEES ARE BASED ON THE$122 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECENED CHECK# RECEIVED BY DATE RECENED <br /> SR <br /> EH 23 032(REVISED 07/21/10) <br />