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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/chd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> A o,?c-) Sett L,Star <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> , s F_ Lou,5e Awe 09 583 fly <br /> CITY STATE I ZIP CODE #OF TANKS AT SITE <br /> L Gt hro P CA �jS33o <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> !sett /e(- - (2yc,C-) Inc. Gno) (-rOwn <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 3P-10 G010 CC4C-P CC. SIJ- tc. 17U 9/6 S.26 6 ''.2,? <br /> ((CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> IC-G nC k o C_O rd o v c' [C, cl S6 7 L7 Closure Installation epair>Retrofit S„2 3�'SS 2' U <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(20042007) 2004 2005 2006 2007 2008 2009 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2009) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> a <br /> TANK PENALTY ASSESSED <br /> a <br /> TANK SURCHARGE=$15/TANK <br /> a <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Placa <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$345/TANK #TANKS X$345= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> a <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$345/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$920/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): `.,`c T 1 I =;-,; < n= 0 ,`1 i 3 9 1 <br /> $ <br /> TANK RETROFIT REPAIR FEE _$345/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, -, ; / ✓ <br /> spill buckets,sumps,mist. <br /> $ <br /> PIPING REPAIR FEE _$345/FACILITY use for piping,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> a <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $115/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE - 115/HOUR <br /> SAMPLING INSPECTION FEE _ $115/HOUR <br /> ALL FEES ARE BASED ON THE$115 HOURLY RATE. TIME THAT EXCEEDS FEES PAID VALL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST 0 1 FACILITY D AMOUNT RECEIVED CHECK 8 RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07/01!08) <br />