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litUEIVED <br /> SAN JOAQUI(N COUNTY <br /> ENVIROWENTAL HEALTH DEPARTMENT OCT 0 9 2014 <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-34.33 Web:www.s'cchd le— IR <br /> FACILITY NAME FACILITY CONTACT NAME INVUNIMFNIJAI EALTH <br /> TMU�vL O� U VbyT <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1-1% , sCY [ k-f . M ga3- W71 <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> y� CA Cp <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 11 s CVs <br /> CITY STAIE ZIP Cl-Q CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure lnss.allation Aepair jBelrorit <br /> ACTIVE FACILITY <br /> 2009 2010 2011 2012 2013 2014 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK <br /> $130 PER TANK AFTER FIRST TANK $ <br /> $ j <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=S15/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.09;FACILITY <br /> PERMANENT CLOSURE <br /> Remi ral or Permitted Closure in Place <br /> TANK ID Ir(s): CLOSURE FEE=S390/TANK #TANKS X$390= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$390 1 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s). PLAN CHECK FEE_$10401 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): t <br /> S <br /> TANK RETROFIT REPAIR FEE _$3901 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> ill buckets,sumps,misc. <br /> S <br /> PIPING REPAIR FEE_$3901 FACILITY use for piping,under-dispenser containment.ect. <br /> MISCELLANEOUS <br /> i <br /> TRANSFER FEE _ $25 <br /> i <br /> CONSULTATION FEE = $130!HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 1301 HOUR $ <br /> SAMPLING INSPECTION FEE = S 1301 HOUR $ <br /> FEES ARE BASED DN THE$130 HOURLY RATE.TIME THAT EXCEEDS FEES PAID WILL BE BALED TO APPLICANT. <br /> TOTAL AMOUNT DUE S <br /> OFFICE USE ONLY ' <br /> SERVICE REQUEST# FACILITY W AMOUNT RECEIVED CHECK*. RECEIVED BY DATE FtECELVED <br /> EH 23 032(REVISED 08-D4.14) <br /> 9Z'd 696996860Z wne10-11ed elge!la2i 80 L:0 b 6 60 100 <br />