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3A1V JOAQUIN k-OUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />30s .st Weber Avenue, 3rd Floor, Stockton, CA 95202-_,08 <br />Telephone: (209) 468-3420 Fax (5`h floor): (209) 468-3433 Web: www.sjo�v_or /g ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />FACILITY ADDRES <br />SITE PHONE # WITH AREA CODE <br />1 <br />skD 836-�`xsd <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />CONTRACTOR ICC # <br />CA <br />4P <br />I APPI If AAIT R11 I IkI/^_ ►tAuc <br />- <br />Sl1i u•C� J� r <br />Hrr4-1t AN1 GUNIAQI NAME <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />(AL <br />(4bR i3 -60 SE <br />CITY <br />STATE <br />ZIP. CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />Closure Installationepair Retrofit <br />3 i i 5 3 I -.UT- <br />A!` I\lc -.. ITV <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): CLOSURE FEE _ $285 / TANK # TANKS X $285 = <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): CLOSURE FEE _ $285 / TANK # TANKS X $285 = <br />TEMPORARY CLOSURE <br />Pian Review and Inspections) <br />TANK ID # (s).*: <br />TEMPORARY CLOSURE FEE _ $285 / FACILITY <br />ALLATION PLAN CHECI <br />Check and Construction I <br />I TANK ID # (s) : I PLAN CHECK FEE = $760 / FACILITY I $ <br />REPAIR PLAN CHECK <br />TANK ID # s <br />TANK RETROFIT REPAIR FEE = $285 / FACILITY use for monitoring equipment, s ill buckets, tank sum s, mise. <br />PIPING REPAIR FEE = $285 / FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 95/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 95 /HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 95/ HOUR <br />ALL FEES ARE BASED ON THE S95 HOURLY RATE TIME TWAT evreenc ecce <br />$ <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 01/29/071 <br />