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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 Fox:(209)468-3433 Web:www,sigov.org/ehd <br /> FACILITY NAME FACILITY CONTACT,j1AME <br /> s�S e_T" - 14tA.L <br /> FACILITY ADDRESS SI�TJE�PHON[E�#�WITH AREA CODE <br /> CITY STATE ZIP CO E T*OF TANKS AT SITE <br /> CAZ <br /> APPLICANT44WgMKNAME APPLICANT CONTACT NAME <br /> APPLI ANT MAILING ADDRESS APPLICANT PHON VE.WITH AREA CODE <br /> 0� 4G4- 3 <br /> CITYI STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> JTG ' G Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2003 2008 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2002-2007) 2004 2005 2006 2007 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) <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=$24.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s : I CLOSURE FEE_$294/TANK F #TANKS X$294= $ <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <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#(a): <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets sums misc. <br /> PIPING REPAIR FEE _$294/FACILITY use for pipIng,under-dispenser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $98/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR $ <br /> SAMPLING INSPECTION FEE = $98/HOUR $ <br /> ALL FEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 12/71/07) <br />