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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. Hazelton Ave., Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd FACILITY NAME FACILITY CONTACT NAME M41 21NA Cil s c--:(- FACILITY ADDRESS SITE PHONE # WITH AREA CODE �v649 c� g5 -IS CITY I STATE I ZIP CODE I # OF TANKS AT SITE s l�C(G TCSrtI CA I 9So-� $ APPLICANT BILLING NAME APPLICANT CONTACT NAME Dow --g- q3t'-)e GOk Y -(z c4mZ0 C' ( (ern I um t-� APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE aaas RNLQ '3A'O k�-- -;M S37-9 9 CITYI STATE I ZIP CODE CIRCLE WORK TO BE DONE I CONTRACTOR ICC # p Closure Installationa ai Retrofit I E5 3114 5;'4 ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $375 / TANK 2008 2009 2010 2011 2012 2013 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) IYIO*4 [ SYSZ'llErri CE 2t1 FKArfot,/ $ � � PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, eat. . $ SAMPLING INSPECTION FEE = $ 125/ HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED TANK SURCHARGE = $15 / TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $375 / TANK # TANKS X $375 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE= $375 / FACILITY ALLATION PLAN CHECK i Check and Construction Ir TANK ID # PLAN CHECK FEE = $1000 / FACILITY REPAIR PLAN CHECK TANK ID # (s) : $ TRANSFER FEE _ $ 25 TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $ spill buckets, sumps, misc. IYIO*4 [ SYSZ'llErri CE 2t1 FKArfot,/ $ � � PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, eat. . MISCELLANEOUS $ TRANSFER FEE _ $ 25 $ CONSULTATION FEE = $ 125/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 /HOUR $ SAMPLING INSPECTION FEE = $ 125/ HOUR ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED To APPLICANT. TOTAL AMOUNT DUE I b�17,5 OFFICF HRF ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED EH 23 032 (REVISED 111612013 by KF)