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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: www.sjgov.orv_/ehd <br />ou <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />v n <br />dim (X�"vcf <br />ADDRESS <br />—hill) <br />SITE PHONE # WITH AREA CODE <br />l �� <br />F�"rnncnt 3 <br />26' qQI-&337 <br />CITY <br />STATE <br />ZIP CODE <br />I # OF TANKS AT SITE <br />tb mtct o <br />CA <br />Ci e- a C - <br />Closure Installation air Retrofit <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />Eui� T c��s Mc, � <br />dim (X�"vcf <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />25ltE, <br />1, <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK O BE DONE <br />CONTRACTOR ICC # <br />c <br />Closure Installation air Retrofit <br />TANK PENALTY ASSESSED <br />H"11YC rA1I1-11 1 <br />TANK ID # (s): CLOSURE FEE = $375 /TANK #TANKS X $375 = <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) <br />$125 PER TANK AFTER FIRST TANK <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): CLOSURE FEE = $375 /TANK #TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />PLAN CHECK <br />Construction In <br />TANK ID # <br />PLAN CHECK FEE = $1,000 / FACILITY <br />REPAIR PLAN CHECK <br />$ <br />TANK ID # (s) : <br />$ <br />TANK RETROFIT REPAIR FEE $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />s ill buckets sum s, mist. <br />--------- — <br />-- <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE _ $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 125/ HOUR <br />ALL FEESAREBASED ON THE 5125 HOURLY ReTF TuuF TWAT ovi- - <br />$ <br />a v ArrLwA1V I . <br />TOTAL AMOUNT DUE $ <br />FFICE USE ONLY <br />?RVICE REQUEST # I FACILITY ID 1 AMOUNT RECEIVED CHECK # f!7� <br />123 032 (REVISED 0811111 by KF) <br />s <br />