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i YCl SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj ov.or /� ehd FACILITY NAME FACILITY FACILITY CONTACT NAME CrJ N l t ` FACILITY ADDRESS SITE TE PHONE # WITH AREA CODE Z 1K5 ire. CITY I STATE I ZIP CODE # OF TANKS AT SITE Z) OLM650—N CA APPLICANT BILLING NAME I APPLICANT CONTACT NAME CrJ N 2006 APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2009 12-00 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # Z) OLM650—N C"l' J Closure Installatio e ' Retrofit ivY rm%,n-i1 T TANK ID # s 0 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) r$550FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) PER TANK AFTER FIRST TANK 2006 2007 2008 2009 2010 2011 $ $5 TANK PENALTY ASSESSED $ TANK SURCHARGE = $15 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY $ PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # s CLOSURE FEE = $375 / TANK# TANKS X $375 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $375 / FACILITY ALLATION PLAN CHECK Check and Construction In TANK ID # (s) : I PLAN CHECK FEE = $1,000 / FACILITY I $ REPAIR PLAN CHECK TANK ID # (s) : $ TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $� s ill buckets, sum s, misc. $ PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) $ MISCELLANEOUS TRANSFER FEE _ $ 25 $ CONSULTATION FEE _ $ 125/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR $ SAMPLING INSPECTION FEE _ $ 125/ HOUR Al I FFFS ARF RAQcn nu $ .__ .._ -.._. TOTAL AMOUNT DUE $ OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED EH 23 032 (REVISED 08/1/11 by KF)