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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.silzov.org/chd APPLICANT BILLING NAME FACILITY CONTACT NAME .S MQY UJec*&Uj- q APPLICANT PHONE # WITH AREA CODE - 3 Oa.4+ R icvv a.( Tl kms. SITE PHONE #WITH AREA CODEf-k06 EFACILITYNAME STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # STATE ZIP CODE # OF TANKS AT SITE �� CA APPLICANT BILLING NAME APPLICANT CONTACT NAME 1Alote VlaL.i.L.Lte_ttim.c a Yee . APPLICANT MAILING ADDRESS MQY UJec*&Uj- q APPLICANT PHONE # WITH AREA CODE - 3 Oa.4+ R icvv a.( Tl kms. 'f CF al -a - &03 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # $ e/t Qs- Closure Installationa air etrofit ACTIVE FACILITY TANK ID# s CLOSURE FEE = $315 / TANK #TANKS X$315= $500 FEE INCLUDES FACILITY FEE + 1 TANK (2003-2008) $550 FEE INCLUDES FACILITY FEE + 1 TANK (2009) $125 PER TANK AFTER FIRST TANK 2004 2005 2006 2007 2008 2009 $ $ TANK PENALTY ASSESSED $ TANK SURCHARGE=$15/TAW $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY $ PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID# s CLOSURE FEE = $315 / TANK #TANKS X$315= TEMPORARY CLOSURE Plan Review and Ins ctions TANK ID # (a): TEMPORARY CLOSURE FEE = $315 / FACILITY TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, for 3 MISCELLANEOUS TRANSFER FEE _ $ 20 $ CONSULTATION FEE _ $ 105/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR $ SAMPLING INSPECTION FEE _ $ 105/ HOUR ALL FEES ARE BASED ON THE S10% NnORI V RATF $ OFFICE USE ONLY SERVICE REQUEST* I FACILITY ID I AMOUNT RECEIVED CHECK # RECEIVED BY I DATE RECEIVED SR EH 23 032 (REVISED 02(23109)