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• SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.or2/ehd FACILITY NAME FACILITY CONTACT NAME 01l`r /" to bfi6 FACILITIY ADDRESS SITE PHONE#WIT EA CODE CITY I STATE ZIP CODE #OF TANKS AT SITE e,�� CA I �L— APPLICANT BILLING NAME APPLICANT CONTACT NAME AA1PPLIC NT MAILING ADDRESS 11 L APPLICANT PH #WITH AREA CODE A Z S 1J, L G7�`CJ�f 3 -C -00 O v31 BE Sr CITY STATE ZIP CODE CIRCLE WORK TO DONE CONTRACTOR ICC# `-(0. Closure Installation Repair Retrofit ACTIVE FACILITY 2003 2004 2005 2006 2007 2008 $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) $ $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED TANK SURCHARGE=$15/TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place) n TANK ID#(s): CLOSURE FEE=$315/TANK /^#TANKS X$315= $fo30 TEMPORARY CLOSURE Plan Review and Inspections) $ TANK ID#(s): TEMPORARY CLOSURE FEE=$315/FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID#(s): PLAN CHECK FEE=$840/FACILITY REPAIR PLAN CHECK TANK ID#(s): $ TANK RETROFIT REPAIR FEE =$3151 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, spill buckets,sumps,misc. $ PIPING REPAIR FEE =$315/FACILITY use for ing,under-dispenser containment,ect. MISCELLANEOUS $ TRANSFER FEE _ $20 $ CONSULTATION FEE = $105/HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $105/HOUR $ SAMPLING INSPECTION FEE _ $105/HOUR ALL FEES ARE BASED ON THE$108 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED I CHECK# RECEIVED BY I DATE RECEIVED SR EH 23 032(REVISED 7/18/08)