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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: y�Wy51goy,org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />�- ej" 1116-1Ct9 <br />At C (A W <br />Y V I A-F✓l. A- C. 01( <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />( 3 C1 5 -oA N-, '� C. r - <br />2006 <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />Vlnr�Ca <br />CA <br />gs33G <br />Closure Installation epair Retrofit <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />W Qr (- T -o-4 t'. c r -C Fi@�(L�►¢C . C - <br />At C (A W <br />Y V I A-F✓l. A- C. 01( <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />P. Q. Box (0zr <br />2006 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />W . S —© <br />A— <br />�J S6 9 t <br />Closure Installation epair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $294 / TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (20,08 & Nihm <br />$ <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 = $294 / TANK <br /># TANKS X $294 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Ir <br />TANK ID # (s) : I PLAN CHECK FEE = $784 / FACILITY <br />$ <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY use for monitoring equipment, s ill buckets, tank sumps, mist. <br />$ z <br />PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect. <br />$ <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 98/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />ALL FEES ARE BASED ON THE $98 HOURLY RATE. TIME THAT ExcEEDS FEES PAID WILL BE BILLED TO AI <br />r)FFU'F IISF ONLY <br />SERVICE REQUEST 11 FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 08/3/07) <br />