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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (54floor): (209) 468-3433 Web: www.sjeov.orz1ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Sa-�e' <br />�(2cnOv �3Y�u-t-o�� <br />FACILITY ADORES <br />SITE PHONE #WITH AREA CODE <br />) Qoiyivi <br />(-,to ti) z"a-4 o9 <br />CITY <br />I STATE <br />ZIP CODE <br />I # OF TANKS AT SITE <br />Sfockfoo <br />I CA <br />gSA6 ri <br />1 3 <br />APPLICANT BILLING NAME <br />APPALI'CANT CONTACT NAME <br />CLOSURE FEE= 279/TANK <br />!r <br />APPLICANT MAILING ADDRESS <br />APPLICANT PO -NE # WITH AREA CODE <br />) Qoiyivi <br />(-,to ti) z"a-4 o9 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />'S(LL'L <br />Lf A. <br />I Q �-/ % '?, <br />Closu Installation epair Retrofit <br />I r:�sa) 0a-1- u r <br />ACTIVE FACILITY <br />TANK ID# (s): <br />CLOSURE FEE= 279/TANK <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />2005 <br />$500 FEE INCLUDES FACILITY FEE+ 1 TANK <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 /TANK <br />$ <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= 279/TANK <br />#TANKSX$279= <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use fo monitodn a ui m , spill buckets, tank sumps, mist. <br />PIPING REPAIR FEE = $279 / FACILITY use for piping, under -dispenser containment, ect. <br />$ a7y.4 <br />MISCELLANEOUS <br />I FACILITY ID <br />I AMOUNT RECEIVED <br />$ <br />TRANSFER FEE _ $ 20 <br />I DATE RECEIVED <br />SR <br />$ <br />CONSULTATION FEE _ $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO <br />OFFICE USE ONLY <br />SERVICE REQUEST# <br />I FACILITY ID <br />I AMOUNT RECEIVED <br />I CHECK# <br />I RECEIVED BY <br />I DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 02/22105) <br />