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04/09/2008 14 : 23 FAX 170744GG192 TANK-TEh; Z 004/004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,P Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(YhJloor):(209)465-3433 Web:www.sieov.ory/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Poo b b <br /> FACILITY ADDRESS SITE PHON THA AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> I7 hlv_-� CA 2 S <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Tan K-Tty— �C e�' orz <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 601 S\ m'\m QA h t33b 4k46 -61s) <br /> CITY STATE ZIP CODE i CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> S Closure Installation Repa Retrofit <br /> ACTIVE FACILITY <br /> 2002 2003 2004 2005 2006 2007 <br /> 5500 FEE INCLUDES FACILITY FEE+1 TANK <br /> 5125 PER TANK AFTER FIRST TANK $ <br /> $ <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=S285/TANK F TANKS X$285= <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ectlons <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$285/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Cheok and Construction Inspections) <br /> TANK ID 9(a); PLAN CHECK FEE=$760 I FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s)! <br /> $ <br /> TANK RETROFIT REPAIR FEE �S285/FACILITY use for mon[toring a ul ment,spill buckets,tank sumps,mise. <br /> S <br /> PIPING REPAIR FEE =S285/FACILITY uee for I in ,under-dls enser containment,act.) <br /> MISCELLANEOUS <br /> TRANSFER FEE = $20 <br /> S <br /> CONSULTATION FEE _ $951 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $95/HOUR <br /> S <br /> SAMPLING INSPECTION FEE = S 951 HOUR <br /> ALL FEES ARE BASED ON THE SGS HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST4 1 FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01129/07) <br />