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' SAN JOAQUIN COUNTY <br />ENVIRONMF.NTAI. HEAL I] I DI:I'ARI'MEN 1 <br />304 East Weber Avenue, 3"' Floor, Stockton, CA 95202-2708 <br />Telephoire: (209) 468-3420 Fax (Sr1' floor): (209) 468-3433 Web: www.sjgQy,org/ehd <br />FACILITY NAME/ <br />TANK ID # s <br />FACILITY CONTACT NAME <br />f:o,� -Fc�tkkp <br />6m e 1 1/ <br />J/1,5 <br />FACILITY ADDRES <br />If <br />SITE PHONE # WITH AREA CODE <br />�6 <br />6�rG�ct�� o D ,It, <br />20 <br />CITY <br />ZIP CODE <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />77� e. <br />ti <br />CA <br />2 5- / <br />z <br />APPLICANT BILLING NAME <br />TANK ID # s <br />APPLICANT CONTACT NAME <br />f:o,� -Fc�tkkp <br />6m e 1 1/ <br />114,14 E. <br />APPLICANT MAILING ADDRESS <br />If <br />APPLICANT PHONE # WITH ARE CODE <br />ZB�S f�a��roc�_ 14vc, <br />20 25-3`%-9-39 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />GErrLos <br />C,q <br />�S-Tp <br />Closure Installationepair Retrofit <br />ACTIVE FACILITY <br />TANK ID # s <br />CLOSURE FEE = $285 / TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 95 / HOUR <br />SAMPLING INSPECTION FEE _ $ 95/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <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 # s <br />CLOSURE FEE = $285 / TANK <br /># TANKS X $285 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $285 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : <br />PLAN CHECK FEE = $760 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID# s <br />TANK RETROFIT REPAIR FEE _ $285 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />PIPING REPAIR FEE = $285 / FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 95/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 95 / HOUR <br />SAMPLING INSPECTION FEE _ $ 95/ HOUR <br />ALL FEES ARE BASED ON THE $95 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 01129107) <br />