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08/21/2006 15:54 4640138 ENIIIP"ENTAL HEALTH PAGE 01 <br /> SAN OA QUIN COUNTY <br /> ENVIRONMENTAL HEALTH DFPARTMENI <br /> 304 East Weber Avenue.3'd Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fas(S'A floor):(209)468-3433 Web:www.s OV.Orglch3 <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS 51TE PHONE 1I WITH AREA CODE <br /> CITY STATE ZIP COD #OF TANKS AT SITE <br /> CA r" i <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE IR <br /> ;WKK TO 13E DONE CONTRACTOR ICC 0 <br /> ` Closure Inswbtlon Repair Retrofit <br /> ACTIVE FACILITY <br /> 2001 2002 2003 2004 2005 2006 <br /> 5500 FEE INCLUDES FACILITY FEE+1 TANK <br /> 4125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE-$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALRE=ADY ON INVENTORY IN A COPA PROGRAM=324.00/FACILITY <br /> P RM ENT CLOSURE <br /> Removal or Permitted Closun?in Place <br /> TANK ID s CLOSURE FEE-5285/TANK #TANKS X$285= <br /> TEMPORARY CLOSURE <br /> (Pl2n Review and Inspections) � <br /> TEMPORARY CLOSURE FEE=$285!FACILITY <br /> TANK ID#(s): <br /> INSTALLATION PLAN CHECK <br /> Plan Check and ConsWcflon In Lions $ <br /> : PLAN CHECK FEE=$760/FACILITY <br /> TANK ID#(s) <br /> REPAIR PLAN CHECK <br /> TANK IDS : �' <br /> ill buckets,tank sum ,mise. C <br /> TANK RET_ROFIT REPAIR FEE 5285/FACILITY use for monitorin ► s <br /> PIPING REPAIR FEE =5285/FACILITY use for under er containment.est <br /> MISCELLANEOUS $ <br /> TRANSFER FEE - S20 $ <br /> CONSULTATION FEE = S 95/HOUR b <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 95/HOUR $ <br /> SAMPLING INSPECTION FEE = S 99/HOUR <br /> ALL FEES ARE BASED ON THE$f5 HOURLY RATE- TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPUCANT. <br /> OFFICE USE ONLY RECEIVED 8Y DATE RECEIVED <br /> SERVICE FtEQt1EST• FACILITY ID AMOUNT RECEIVED CHECK <br /> SR <br /> EN 23 o1Z(REVISED o72111m) <br />