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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 Fra: (209) 468-3433 Web: www.sjeov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />SaEewa <br />ate& -t ,7 -13v't-Eo,A <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />to 4 a -s ti �cL - 4�C 7k),Q <br />ac 411— W) C) <br />CITY I STATE <br />ZIP CODE I # OF TANKS AT SITE <br />S-EnCV-AtJA CA <br />3 <br />APPLICANT BILLING NAME <br />TANK ID # (a): <br />APPLICANT CONTACT NAME <br />2003 <br />2004 <br />��k{,L � r,� <br />APPLICANT MAILING ADDRESS <br />2007 <br />APPLICANT He <br /># WITH AREA CODE <br />00 kULVI,u AU'Q <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />,3.(3 -(eo3 g <br />CITY STATE <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />CZA <br />if <br />closure Closure Installation 4a ai Retrofit <br />ACTIVE FACILITY <br />TANK ID # (a): <br />CLOSURE FEE = $294 / TANK <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$ 31� <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />1 <br />1 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <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 />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (a): <br />CLOSURE FEE = $294 / TANK <br /># TANKS X $294 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />REPAIR PLAN CHECK <br />I FACILITY ID <br />TANK ID # (s) : <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, mist. <br />PIPING REPAIR FEE = $294 / FACILITY use for piping, under -dispenser containment, set. <br />$ 31� <br />MISCELLANEOUS <br />I FACILITY ID <br />AMOUNT RECEIVED <br />$ <br />TRANSFER FEE _ $ 20 <br />DATE RECEIVED <br />SR <br />$ <br />CONSULTATION FEE = $ 98/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 98/ HOUR <br />ALL FEES ARE BASED ON THE $98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT, <br />OFFICE USE ONLY <br />SERVICE REQUEST# <br />I FACILITY ID <br />AMOUNT RECEIVED <br />CHECK <br />I RECEIVED BY <br />DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 12131107) <br />(' tv UM <br />Lj <br />