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Jul 07 06 09: 44a Jeffrey C. Henley 714-739- 1499 � p. 8 S%-N JOAQITIN COUNT' ENVIRONMENTAL HEALTH DEPARTMENT 304 East Weber Avenue,3r6 floor,Stockton,CA 95202-2708 Telephone:(209)468-3420 Fax(54 loon):(209)468-3433 Web:www.si og v.or FACILITY NAME FACILITY CONTACT NAME pY So FACILITY ADDRESS SITE PHONE#WITH AREA CODE CITY I STATE ZIP CODE #OF TANKS AT SITE T�z- -• CA �i 5 3 APPLICANT BILLING NAME APPLICANT CONTACT NAME 11!�'_j? c: -4jr-Cc 1 O O ?6wt APPLICANT MAILING ADDRESS APPLICANT PHONE S WITH AREA CODE ..7+_+ 31 S `^ + _+c=� 2 -7-7 S '� �� CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# Closure Installatione Jrr-.Retrofit 2_S3.6 ACTIVE FACILITY j 2000 2001 2002 2003 2004 2005 $500 FEE INCLUDES FACILITY FEE+1 TANK $125 PER TANK AFTER FIRST TANK - - — $ TANK PENALTY ASSESSED _TANK SURCHARGE=$15/TANK _ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ PERMANENT CLOSURE (Removal or Permitted Closure in Place TANK ID#(s): CLOSURE FEE=$2791 TANK #TANKS X$279= TEMPORARY CLOSURE Plan Review and Inspections) $ TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) —� TANK ID#(s): PLAN CHECK FEE_$744/FACILITY REPAIR PLAN CHECK TANK ID#(s): TANK RETROFIT REPAIR FEE =$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) PIPING REPAIR FEE _$279 I FACILITY (use for piping,under-dispenser containment,ed. MISCELLANEOUS TRANSFER FEE _ $20 CONSULTATION FEE _ $93/HOUR UNAUTHORIZED RELEASE EVALUATION FEE _ $93 1 HOUR SAMPLING INSPECTION FEE _ $931 HOUR ALL FEES ARE BASED ON THE$93 HOURLY RATE- TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPUCANT. OFFICE USE ONLY SERVICE REQUEST it FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED SR EH 23 032(REVISED 02122105)