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SAN JOAQ1COUNTY RECEIVE D <br /> ENVIRONNtEN"IAL HEAEA LTD <br /> H EPARTMENT <br /> 1868 E. Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 11eh: ww%v.sjcchd.conl SEP 2 8 Z016 <br /> FACILITY NAME FACILITY CONTACT NAME <br /> PG&E Kristin Brown ENVIRONMENTAL HEALTH <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE DEPARIMENT <br /> 4040 West Lane 916 224-7280 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton ICA 95204 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Tait Environmental Kristin Brown <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 11280 Trade Center Drive 916 224-7280 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Rancho Cordova Closure Installation Repair)Retrofit 5252163 <br /> ACTIVE FACILITY <br /> (As of 8/1/16) $583 FACILITY FEE+$139 PER TANK 2011 2012 2013 2014 2015 2016 <br /> Facility Fee NO LONGER INCLUDES FIRST TANK <br /> (2011-Aug 1,2016)$550 FEE INCLUDES FACILITY FEE+1 TANK $ <br /> $130 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$15/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$417/TANK #TANKS X$417= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$417/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE=$1112/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK RETROFIT REPAIR FEE =$417/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc.) <br /> $ 417.00 <br /> PIPING REPAIR FEE=$417/FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $ 139/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $139/HOUR $ <br /> SAMPLING INSPECTION FEE = $ 139/HOUR $ <br /> FEES ARE BASED ON THE$139 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE 1 $417.00 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 07-152016) <br />