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SAN JOAQUIN COUNTY SEC ENED <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 (5 h floor): (209) 468-3433 Web: www.sj ov.or /g ehd <br />— GAII/10'r hu A'..— ..– - <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />�S <br />PPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2003 <br />AGILITY ADDRESS <br />CITY <br />SITE PHONE # WITM AREA CODE <br />Info 4 Em <br />o L>-qV e, <br />5I— I551 <br />CITY <br />I STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />S <br />CA <br />61521 q <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />CLOSURE FEE = $279 / TANK <br />2000 <br />PPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2003 <br />2004 <br />CITY <br />STATE ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />0 Ii � 5� <br />Closure Installatio Repair Retrofit <br />$ <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 />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 # (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 />TANK ID # <br />CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, s ill buckets, tank sumps, misc.) <br />$ <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <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 />ALL FEES ARE CASED ON THE $v3 HVUKLY KA I L. I IME I HA I 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 />cm L3 uJL ImEvIJCu uL/LLIuJI <br />