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SAN JOAQL!IN COUNTY 'C"Ec wED <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 JUL 1 7 2006 <br />Telephone: (209) 468-3420 Fax (S`1` floor): (209) 468-3433 Web: www.sigov.org/ehd <br />r- A .. <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />L L✓ES <br />PPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />'ZIP <br />/ <br />FACILITY ADDRESS <br />STATE I CODE <br />SITE PHONE # WITIIII AREA CODE <br />l64q Em <br />o 17r' <br />51-1551 <br />CITY <br />ha27�7 'W <br />STATE <br />ZIP CODE # OF TANKS AT SITE <br />SCl <br />CA <br />g521 q 7 - <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />f' CIL <br />% <br />PPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />'ZIP <br />2004 <br />CITY <br />STATE I CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />�J dJ <br />Closure Installatio Repair Retrofit <br />ha27�7 'W <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 />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <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 />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : PLAN CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, spill buckets, tank sumps, misc.) $ <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) $ <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />