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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siiaov.or /g ehd FACILITY NAME FACILITY CONTACT NAME FACILITY ADDRESS SITE PHONE#WITH AREA CODE k1 w . LST c1 CITY STATE ZIP CODE #OF TANKS AT SITE Iprf L CA CA APPLICANT BILLING NAME APPLICANT CONTACT NAME d e� Q a -Pini APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE (001 M C kc&jV-r ';Lo' S�1 -(aovU CITY - STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# Closure Installation Repair Retrofit ACTIVE FACILITY 2006 2007 2008 2009 2010 2011 $500 FEE INCLUDES FACILITY FEE+1 TANK(2006-2007) $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2011) $ $125 PER TANK AFTER FIRST TANK $ 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 INSTALLATION PLAN CHECK Plan Check and Construction Inspections) $ TANK ID#(s): PLAN CHECK FEE=$1,000/FACILITY REPAIR PLAN CHECK TANK ID#(s): TANK RETROFIT REPAIR FEE =$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, spill buckets,sumps,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 $ ALL FEES ARE BASED ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. TOTAL AMOUNT DUE $ OFFICE USE ONLY SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED EH 23 032(REVISED 0811/11 by KF)