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SAN JOAQUIN COUNT' <br /> ENVIRONMENTAL HEALTH DEPARTMEi <br /> 600 East Main Street, Stockton, CA 95202-30z-y <br /> Telephone:(209)468-3420 Fax: (209)468-3433 1,11'eb: www.sj o� v.orgehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FL 1 _� << i'1, 1Ci _C rC <br /> FACILITY ADDRESS SITE PHONE#WITH AREA COD <br /> SS -irerYlpn <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> -tic)r) CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> cr ha Fes) Evo n no Eo rte' <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH ARVA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2003 2004 2005 2006 2007 2008 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <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): CLOSURE FEE=$294/TANK #TANKS X$294= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$294/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$784/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets,sumps,misc.) <br /> PIPING REPAIR FEE _$294/FACILITY (use for piping, under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $98/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR $ <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 APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> Fu)z m>ro;:%7rn i9niir7l <br />