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• SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:—www.silzov.org/ehd <br /> AGILITY NAME FACILITY CONTACT NAME <br /> L� S <br /> PACILI ADDRESS SITE PHONE#WITH AREA CODE <br /> rip S' -- 66 <br /> ITV STATE ZIP CODE #OF TANKS AT SITE <br /> vi CA 2 3 J_— <br /> APPLICANT ME APPLICANT CONTACT NAME <br /> S- tKg � <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> �8 N l_I o S •� -8333 <br /> ITY STATE ZIP CODE CIRCA WORK TO BE DONE CONTRACTOR ICC# <br /> �., Clos e Installs' n Repair Retrofit <br /> ACTIVE FACILITY <br /> 2003 2004 2005 2006 2007 2008 <br /> 500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> 550 FEE INCLUDES FACILITY FEE+ 1 TANK(2008) $ <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 CUPA PROGRAM=$24.00/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID# s : CLOSURE FEE=$294/TANK #TANKS X$294=_ <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$294/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$784/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $ <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> s ill buckets,sum s,mist. <br /> $ <br /> PIPING REPAIR FEE _$294/FACILITY use for piping,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $98/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $98/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE = $98/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 /> 11 SERVICE REQUEST#__j FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 12131107) <br />