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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 Far: (209) 468-3433 Web: www.sj og vorg/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />c{gLi�b?Z�p q r4 <br />Fmk ! —at (f <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />13 yG_> P"I r le- <br />zp8 L3 -33 <br />CITY <br />STATE <br />ZIP CODE # OF TANKS AT SITE <br />f� �✓�ao�� <br />CA <br />4-L re-ilf <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />CLOSURE FEE = $366 / TANK <br />2005 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />F dos t t� <br />2� X23 3313 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />4-L re-ilf <br />:�:A <br />903 -/ <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $366 / TANK <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2005-2007) <br />PIPING REPAIR FEE = $366 / FACILITY use for piping, under -dispenser containment, ect. <br />SAMPLING INSPECTION FEE _ $ 122/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2010) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $366 / TANK <br /># TANKS X $366 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $366 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction In <br />TANK ID # (s) : I PLAN CHECK FEE = $976 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TRANSFER FEE _ $ 25 <br />TANK RETROFIT REPAIR FEE = $366 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, mise[/ <br />PIPING REPAIR FEE = $366 / FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />CONSULTATION FEE _ $ 122/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 122 / HOUR <br />SAMPLING INSPECTION FEE _ $ 122/ HOUR <br />ALL FEES ARE BASED ON THE $122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BiLLED TO APPUCAN i. <br />OFFICE I ISE ONLY <br />[SERVICEREQUEST # FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br />R <br />EH 23 032 (REVISED 07/21/10) <br />