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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.sj o� /8 ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> l :1'a� W'x= { <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> Zai Cool - "T0S8 <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> CA '7�sz>z— L <br /> APPLICANT BILLING NAME APPLICANT CONTACT_NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> a.�Dx �4a7 lz5 sN41-78a!7 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> V4� �6wC CJ4 3 Closure Installation e a Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) 2002 2003 2004 2005 2006 1 2007 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008&New $ <br /> Installs as of 8/1/07) <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 CLOSURE FEE_$294/TANK #TANKS X$294= <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE_$294/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID If(s): PLAN CHECK FEE_$784/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s : <,> S\e-%-4A <br /> $ <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY use for monitoring equipment,s ill buckets,tank sumps,misc. <br /> $ <br /> PIPING REPAIR FEE _$294/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> $ <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# I FACILITY ID I AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 08/3/07) <br />