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1 SAN JOAQUIN COUNTY <br />r • ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (5`Afloor): (209) 468-3433 Web: www.sigov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />SO-Ae..Ix <br />�AeOAkAV- ON <br />FACILITYADDRESS <br />SITE PHONE # WITH AREA CODE <br />2003 <br />8400 <br />CITY <br />I STATE <br />ZIP CODE # OF TANKS AT SITE <br />Staff Eos. <br />I CA <br />45ao'7 3 <br />APPLICANT BILLING NAME <br />TANK ID # s): <br />APPLICANT CONTACT NAME <br />Able. RaZutLemL&.ee, ,tie . <br />9CLV-44 W ei+(U 0 u <br />APPLICANT MAILING ADDRESS <br />2003 <br />APPLICANT PHONE # WITH AREA CODE <br />2005 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />CITY - <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />SOW.'E'0. SC'V <br />$125 PER TANK AFTER FIRST TANK <br />e� <br />QSgFo3 <br />Closure Installation C§ai Retrofit <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 />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 93/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <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 />PERMANENTCLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # s): <br />CLOSURE FEE = $279 / TANK <br /># TANKS X $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 for monitoring equipment. spill buckets, tank sumps, mist. <br />PIPING REPAIR FEE = $279 / FACILITY use for piping, under -dispenser containment, ed. <br />MISCELLANEOUS <br />I FACILITY ID <br />I AMOUNT RECEIVED <br />$ <br />TRANSFER FEE _ $ 20 <br />DATE RECEIVED <br />SR <br />$ <br />CONSULTATION FEE = $ 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 93/ HOUR <br />RRC ORJCV VR THE... RVURIi.IC. IIIYIC IRM1CAMCCVD YCC.I YNIU WILL tlt tl ILLtU IU AFFLIG . <br />OFFICE USE ONLY <br />SERVICE REQUEST# <br />I FACILITY ID <br />I AMOUNT RECEIVED <br />I CHECK# <br />RECEIVED BY <br />DATE RECEIVED <br />SR <br />CR �., 1, C IRCYIJCV V[IGL/VJI <br />