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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.sigov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />' ^ <br />a & <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />,/� �}� D n <br />CJV/v� �ILti-YLI i eo <br />�:CT ( `O , e I cc <br />CITY STATE <br />ZIP CODE # OF TANKS AT SITE <br />S'fOC'v' b"► - <br />CA <br />_ b <br />APPLICANT BILLING NAME <br />APPLICANT CONTACTNAME <br />CLOSURE FEE = $294 / TANK <br />CIS � bA 0 fa, tL L" <br />APPLICANT MAILING ADDRES <br />APPLICANT PHONE # WITH AREA CODE <br />2006 <br />�:CT ( `O , e I cc <br />CITY <br />STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />45U720 ClosureInstallation Repair etrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $294 / TANK <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />nil I On T!1 ADDI 1!`ANT <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK <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 />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $294 / TANK <br /># TANKS X $294 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />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 />spill buckets, sumps, mist. <br />PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect.) <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 />nil I On T!1 ADDI 1!`ANT <br />ALL FttS AM: tIAStU UN 1 ne ;PUG nvunl-i mm 10. n�.�� � �,.., -.. • �--- • •-•- --�-- -- ------ - - <br />^ffl I l= I ICC !1611 V <br />%JFF VL - VI�V <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 12/31/07) <br />