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SAN JOAQUIN IRCOUNTY] <br />ENVIRONMENTAL HEALTH DEPARTMENT E N ! <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s'cehd.co AY 9 <br />FACILITY NAME FACILITY CONTACT NAME <br />L*AMONMEaALH5-1 <br />FACILITY ADDRESS SITE PHONE # WITH AREA CODE ` <br />2011 <br />CITY <br />STATE ZIP CODE <br /># OF TANKS AT SITE <br />CONTRACTOR ICC # <br />CA <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />TANK ID # (s): <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />2011 <br />CITY <br />STATE <br />ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />2016 <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />(As of 8/1/16) $583 FACILITY FEE + $139 PER TANK <br />2011 <br />2012 <br />2013 <br />2014 <br />2015 <br />2016 <br />Facility Fee NO LONGER INCLUDES FIRST TANK <br />PIPING REPAIR FEE = $417 / FACILITY use for piping, under -dispenser containment, ect. <br />(2011 -Aug 1, 2016) $550 FEE INCLUDES FACILITY FEE + 1 TANK_ <br />$130 PER TANK AFTER FI TANK <br />$-41- <br />TANK PENALTY ASSESSED <br />TANK <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CU PA PROGRAM =$35.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $417 / TANK <br /># TANKS X $417 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $417 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : I PLAN CHECK FEE = $1112 / FACILITY <br />0 <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $417 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, misc. <br />PIPING REPAIR FEE = $417 / FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />M -O7 <br />ey M''Nj- <br />CONSULTATION FEE _ $ 139/ HOUR S •' 1 201? <br />U!N <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 139 / HOUR N VIRONIL44 <br />FP cNOIJTq�N� <br />SAMPLING INSPECTION FEE _ $ 139/ HOUR TMENT <br />FEES ARE BASED ON THE $139 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE & ,-- <br />OFFICE USE ONLY <br />SERVICE REQUEST # I FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY I DATE RECEIVED <br />/i l) C -D -- C.0.2174.1 l Sly l 1 % <br />EH 23 032 (REVISED 07-15-2016) (As 4 1 M <br />