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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,6k 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)469-3433 Web:www.sigov.orl7/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1 C� -- �q <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> ca 4 <br /> Lo R <br /> APPLICANT <br /> BILLING NAMr\E APPLICANT CONTACT NAME <br /> APPLICA T MAILING ADDRESS APPLICANTPHONE#WITH AREA CODE. <br /> clnr <br /> `C STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Re it Retrofit <br /> N5/TANK <br /> CILITY <br /> INCLUDES FACILITY FEE+1 TANK(2003-2006) 2004 . 2005 2006 2007 2008 2009 <br /> NCLUDES FACILITY FEE+1 TANK(2009) <br /> ANK AFTER FIRST TANK $ <br /> ALTY ASSESSED $ <br /> HARGE_$15/TANK $ <br /> CHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> tTANK <br /> # s CLOSURE FEE_$315/TANK #TANKS X$315= $ <br /> ARY CLOSURE <br /> view and Ins ections <br /> #(s): TEMPORARY CLOSURE FEE_$3151 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <br /> TANK ID#(s) PLAN.CHECK FEE E$840 FACILITY $ <br /> REPAIR PLAN CHECK. <br /> TANK ID IF(s); <br /> E _$315/FACILITY (use for monitoring equipment,c!starts,!ect-)' ades,TANK RETROFIT•REPAIRFE ✓kets, um s,mist.PIPING REPAIR FEE _$315/FACILITY use for i in ,under dis enser <br /> $ <br /> MISCELLANEOUS <br /> 'TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE $ <br /> _ $105/HOUR <br /> UNAUTHORIZED REI EASE EVALUATION FEE _ $105(HOUR $ <br /> SAMPLING INSPECTION FEE _ $105/HOUR $ <br /> ALC 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 03.2(REVISED 02/23/09) <br />