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• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www si ov.or�/e d <br /> FACILITY CONTACT IdAME <br /> FACILITY NAME //����ff�� G Y/ f W <br /> SITE PHONE#WITH AREA CODE <br /> FACILITY ADDRESS <br /> P CODE <br /> ZI ' #OF TANKS AT SITE <br /> STATE ' <br /> CITY <br /> CA leg <br /> APPLICANT B. ING NAME APPLICANT CONTACT NAME <br /> 444 McAPPLICANT PHONE#YYITH AREA CODE <br /> APPLI ANT MAILING ADDRESS w� ,ZI-7 r <br /> STATE ZIP CODE <br /> CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> CITY ` J/G/ lure Installation Repair. Retrofit <br /> ACTIVE FACILITY 2003 2004 2005 2006 2007 2008 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) $ <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE_$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.001 FACILITY <br /> PERMANENT CLOSURE $ <br /> Removal or Permitted Closure in Place #TANKS X$294= <br /> CLOSURE FEE_$2941 TANK <br /> TANK ID# s <br /> TEMPORARY CLOSURE $ <br /> Plan Review and In ons <br /> TEMPORARY CLOSURE FEE=$2941 FACILITY <br /> TANK ID#(s): <br /> INSTALLATION PLAN CHECK ions $ <br /> Plan Check and ConsUuction l <br /> PLAN CHECK FEE=$7841 FACILITY <br /> TANK ID#(s) <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): ! $ <br /> .. _ _ . ! <br /> TANK RETROFIT REPAIR FEE _$2941 FACILfIY (use for monitoring equipment cold starts,EVR u � <br /> spill buckets,sum mist. $ <br /> PIPING REPAIR FEE _$2941 FACILITY use for ,under-dispenser containment,ect. <br /> MISCELLANEOUS $ <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $981 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR $ <br /> SAMPLING INSPECTION FEE _ $981 HOUR <br /> ALL FEES ARE BASED ON THE$9s HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST 9 FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 12131107) <br />