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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Far: (209) 468-3433 Web: www.sipov.org/ch <br />FACILITY NAME <br />FCACILITY CONT^A�CT NAME <br />saz�-e.�.30L <br />C-1QLL�' L1�1'�C�t <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />�-.`YI, <br />a, <br />CI <br />STATE <br />ZIP CODE # OF TANKS AT SITE <br />SEock �� <br />CA <br />glSa 3 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />,4u[e 6�aiL.��e lacnue-E Tae . <br />APPLICANT MAILING ADDRESS <br />M cz <br />APPLICANT HONE #WITH AREA CODE <br />3��� }2 iaLac �l k� <br />qbo ai3 - locs3 <br />CITY STATE ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />!� <br />Closure Installation a air etroAt <br />j11� (p(f)_ (� <br />ACTIVE FACILITY <br />TANKID#s : CLOSURE FEE =$315/TANK 4TANKS X$315= <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2003-2008) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009) <br />$125 PER TANK AFTER FIRST TANK <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 105/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE =$15/TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />$ <br />PERMANENTCLOSURE <br />Removal or Permitted Closure in Place <br />TANKID#s : CLOSURE FEE =$315/TANK 4TANKS X$315= <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE _ $315 / FACILITY <br />REPAIR PLAN CHECK <br />BILLED <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />s ill -.- sum s, mist. <br />$ <br />PIPING REPAIR FEE = $315 / FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 105/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 105/ HOUR <br />ALL FEES ARE BASED ON THE S105 HOURLY RATE_ TIME TWAT evrcene cat e.,.. ........_ <br />$ <br />D . ==. FAiU ..ALL BE GILLED <br />