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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 Fax: (209) 468-3433 Web: www.si og v.or /g ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />S(ZF�(C C <br />'Q kct-u- -Uv-a'i <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />1<6-64 <br />X0'4 36 %Iq Sb <br />CITY <br />STATE <br />ZIP CODE # OF TANKS AT SITE <br />Tvci-- c <br />CA <br />91S37 C �j <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />�C VC(,�LlcLW <br />S <br />�(tu WeL41, UCL. L <br />APPLICANT MAILING ADDRESS cl <br />(C' 'C) Auk-, <br />APPLICANT PHONE # WITH AREA CODE <br />+8 -(�3-- (D03 g <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />$ <br />(_A <br />CIS -t 4— <br />Closure Installationepair > Retrofit <br />-Q q 5 17 — 0-1 <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $315 / TANK <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 105/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />is <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $315 / TANK <br /># TANKS X $315 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $315 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : <br />I PLAN CHECK FEE = $840 / FACILITY <br />TRANSFER FEE _ $ 20 <br />$ <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, mist. <br />PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.)$ 3 <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 105/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 105/ HOUR <br />ALL FEES ARE BASED ON THE $105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 7/18/08) <br />