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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3`d Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(5'h floor):(209)468-3433 Web:www.sj og v.or /�ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> �)5 A C�Q.-S PR CtAACO <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> Z g 4 0QW e{��t'V1tiC�l.� Gl t d Q .33 q-- o'U.7 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> LcA� CA q S.1 4--�x- 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Sev-V Lt S fiOc1 Sf: o s :[7�t-e-• 4LIl, cl <br /> APPLICANT MAILING ADDRESS APPLICANT P ONE#WITH AREA CODE <br /> bFSO (4Fg L�-[3 (ve 39 <br /> CITY STATE 7JP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> CA `�Sll a. Closure Installation(SpR Retrofit <br /> ACTIVE FACILITY <br /> 2002 2003 2004 2005 2006 2007 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK <br /> $125 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=$24.00/FACILITY $ <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 /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$285/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$760/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$285/FACILITY use for monitoring equipment,s ill buckets,tank sumps,mist. $ <br /> PIPING REPAIR FEE _$285/FACILITY (use for pi ing,under-dis enser containment,ect. $"�"rcz- <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $95/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $95/HOUR $ <br /> SAMPLING INSPECTION FEE = $95/HOUR 1 $ <br /> ALL FEES ARE BASED ON THE$95 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 01/29/07) <br />