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skww SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3"Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(5`"floor):(209)468-3433 Web:w .sieov.ore/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 37-�S lug l 36 - qyz2 <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> CA s3 7 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING AD R SS APIPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation r5TTIDRetrofft <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 2000 2001 2002 2003 2004 2005 <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#(a): CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$744/FACILITY $ <br /> REPAIR FLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,s ill buckets,tank sumps,mist. <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR $ <br /> SAMPLING INSPECTION FEE = $93/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# I FACILITY ID I AMOUNT RECEIVED I CHECK# I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02/22/05) <br />