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SAN JOAQUIN COUNTY <br /> _ r4VIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(S"floor).-(209)468-3433 Web:wwwai oov or /e ehd <br /> FACILITY NAME FACILITY CONTACT NAME - <br /> SCAW0.u Ct-eck' <br /> FACILITY ADDRESS ( SITE PHONE#WITH AREA CODE <br /> AUQ -26 ( <br /> CITY I STATE ZIP CODE TANKS AT SITE <br /> S fF>C�C�OL1 CA 9Sao7 #OF 3 <br /> APPLICANT BILLING NAME APPLICANT CONTENAMEF'tG- ,�APPLICANT MAILING ADDRESS APPLICANT P ONEA CODE3aa-y- (2 Cora �kl„ L0 aa3 -CITY - :STATE 7JPCODE � .CIRCLE WORKE � CONTRACTOR ICG# <br /> Closure Installation Repa(r Retrofi j a SO�o�U ' U <br /> ACTIVE FACILITY <br /> 2004 2005 200 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 2002 2003 6 2007 <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15 1 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 <br /> TANK ID#(s): CLOSURE FEE=$2851 TANK #TANKS X$285= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s)'t - - TEMPORARY CLOSURE FEE_$285/FAC <br /> jLjTY. <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <br /> TANK ID#(a): PLAN CHECK FEE_$760/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(a); - <br /> TANK RETROFIT REPAIR FEE =$285/FACILITY use for monitoring equipment,s ill buckets,lank sumps,misc. $ 0�.9 <br /> PIPING REPAIR FEE _$2851 FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $95/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $951 HOUR $ <br /> SAMPLING INSPECTION FEE = $95/HOUR $ <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# I AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01129107) <br />