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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENI <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (5'hfloor): (209) 468-3433 Web: www.sj og v.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />V I l- L A L 7` 44 Ar2.t Aj <br />M I KL S* j'c�! C 67 <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />6614'1 CM )OARCOWG V DF- <br />(2-011) -- S'5 <br />CITY I STATE <br />ZIP CODE # OF TANKS AT SITE <br />Sroc(c N CA <br />9 /% <br />APPLICANT BILLING NAME <br />TANK ID # (s): <br />APPLICANT CONTACT NAME <br />!4 LL -1`E -C <br />2001 <br />441g -C- JLOTT-G-� <br />APPLICANT MAILING ADDRESS <br />2004 <br />APPLICANT PHONE # WITH AREA CODE <br />17 '7S- c 0017MC vP <br />C (2 <br />20 s3a - 7 3 a d <br />CITY STATE <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />q6--7 <br />Closure Installatio ,pair etrofit r2s J�{IZ—( <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 />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />$ <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 = $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 />TRANSFER FEE _ $ 20 <br />TANK ID # (s) : <br />PLAN CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID#s: <br />L t- D <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitorin a uipment, ill buckets, tank sumps, misc.) <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECENED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 02122/05) <br />