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08/21/ 906 15:54 4640130 ENVIRONMENTAL HEALTH PAGE 01 <br /> SAN JOAQM COUNTY <br /> ENVTRONMENIAi.HEALTH DEPARTMENT <br /> 304 East Weber Avenue.3'a Floor,Stockton,CA 95202-2708 <br /> relephone:(209)468-3420 F"(5,"`'floor):(209)468-3433 Web:www-s' ov.org/chd <br /> aL <br /> F <br /> ACILITY NAME FAC ITY CONTACT NAME <br /> tv <br /> ACILITYQ RESS SITE PHONE#WITH AREA CODE <br /> C7a 1 l A-Op— 3'�d—DQ <br /> CITY STATE I ZIP CODE I #OF KS AT SITE <br /> CA �( <br /> APPLICANT BILLING NAME APP ANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APP UC PHONE 9 WITH AREA CODE <br /> R-A-553(p 'Apt- <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC A <br /> Closure Instaflatton Re el M _j <br /> ACTIVE FACILITY <br /> 2001 2002 2003 2004 2005 2006 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK <br /> X125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE-$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM'324.00/FACILITY <br /> P RMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$2851 TANK A TANKS X$285 r <br /> TEMPORARY CLOSURE <br /> an RevIDW and to ctions <br /> TANK ID It(s): TEMPORARY CLOSURE FEE_$285/FACILITY <br /> INS ALU—TION PLAN CHECK <br /> Plan Chock and Construction In dions $ <br /> TANK ID#(s); PLAN CHECK FEE=$760/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $, <br /> TANK RETROFIT REPAIR FEE _$285/FAGLI rY use for rnoTitcxing e4uls iU budcats,tank sum ,misc. <br /> PIPING REPAIR FEE =$285/FACILITY use for under er containment,ert <br /> MISCELLANEOUS <br /> TRANSFER FEE ' S20 $ <br /> CONSULTATION FEE _ $95/WOUR b <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 45/HOUR $ <br /> SAMPLING INSPECTION FEE = S 951 HOUR <br /> ALL FEES ARE ED—THE 505 HOURLY RATE- TIME THAT EXCEEDS FEES PAID WILL BE 91LLEO TO APPUCAHT. <br /> OFFICE USE ONLY <br /> SERVICE REQt1EST i PAUCITY ID IWOUNT RECEIVED CHECK>t RECEIVED BY DATE RECEIVED <br /> SR <br /> SERVICE <br /> rH 23 032IRFVISED 0712&06) <br />