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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.sjgov.or /g ehd FACILITY NAME FACILITY CONTACT NAME I APPLICANT CONTACT NAME lH FACILITY ADDRESS SITE PHONE # WITH AREA CODE '101 E- , wn- ea -6 v w Ry `01- C Z50E CITY I STATE ZIP CODE # OF TANKS AT SITE l3 \ CA 9 CIRCLE WORK TO BE DONE APPLICANT BILLING NAME 2003 I APPLICANT CONTACT NAME 2005 's In L 6im 10hik) APPLICANT MAILING ADDRESS $500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) APPLICANT PHONE # WITH AREA CODE # TANKS X $315 = _- . CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # kClosure INSTALLATION PLAN CHECK Plan Check and Construction Inspections) Installation Repair Retrofit TANK PENALTY ASSESSED ACTIVE FACILITY TANK SURCHARGE = $15 / TANK 2003 2004 2005 2006 20 07 20 08 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) TANK ID # (s): CLOSURE FEE = $315 / TANK # TANKS X $315 = TEMPORARY CLOSURE (Plan Review and Inspections) PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) TANK ID # (s) : $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) $125 PER TANK AFTER FIRST TANK $ SAMPLING INSPECTION FEE = $ 105/ HOUR INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID # (s) : TANK PENALTY ASSESSED $ TANK SURCHARGE = $15 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY $ TRANSFER FEE _ $ 20 $ PERMANENT CLOSURE Removal or Permitted Closure in Place 1 TANK ID # (s): CLOSURE FEE = $315 / TANK # TANKS X $315 = TEMPORARY CLOSURE (Plan Review and Inspections) PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) TANK ID # (s) : TEMPORARY CLOSURE FEE = $315 / FACILITY $ SAMPLING INSPECTION FEE = $ 105/ HOUR INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID # (s) : PLAN CHECK FEE = $840 / FACILITY $ REPAIR PLAN CHECK TANK ID # (s) : $ TRANSFER FEE _ $ 20 $ TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, 1 spill buckets, sumps, misc.)` $ PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 105/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR $ SAMPLING INSPECTION FEE = $ 105/ HOUR ALL rCCJ AK= t5AD=U UN I Ht y9Ut, HUUKLY KA i t. I IML I HAI LXGttUS t-tt5 I AIU WILL Ct bILLtU I U AYYLII.AN I. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR :H Z3 U32 (Kt VISED 7/18/08)