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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3`d Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(5`h floor):(209)468-3433 Web:www.sigov.or_g/ehd <br /> FACILITY NAME FACILITY CONTA NAME <br /> w i /ice 'o <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 5 , gl� 373— i I S7- L.�l-��? <br /> CITY STATE ZIP CODE / #OF TANKS AT SITE <br /> ✓/a� CA I ' Zz Z <br /> APPLICANT BILLING NAME APPLICANT C NTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> Pd -;7-, Orc 3 73 -l1SZ <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure nstallatio Repair Retrofit <br /> ACTIVE FACILITY J j In 5 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 2000 2001 2002 2003 2004 20 5 <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ -30 <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE S S <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) 7� 6 <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY $ -7 y� <br /> REPAIR PLAN CHECK 141V /3/ 17(D'-/ <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,mist.) $ <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <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# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02/22/011 <br />