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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.sigov.org/ghd FACILITY NAME FACILITY CONTACT NAME "Dec) FACILITY ADDRESS SITE PHONE#WITH AREA CODE �(,-,- t Lo v ( 2.0 L1}l0 CITY STATE ZIP CODE I #OF TANKS AT SITE CA CD APPLICANT BILLING NAME APPLICANT CONTACT NAME APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE 0 qVQpASAN LA '� `T 3 L 12 1p CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# 0�1 Closure Installatio Repair Retrofit ACTIVE FACILITY 2002 2003 2004 2005 2006 2007 $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) $550 FEE INCLUDES FACILITY FEE+1 TANK(2008&New $ Installs as of 8/1/07) $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED TANK SURCHARGE=$15/TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$24.00/FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID#(s): CLOSURE FEE=$294/TANK #TANKS X$294= TEMPORARY CLOSURE Plan Review and Inspections) TANK ID#(s): TEMPORARY CLOSURE FEE_$294!FACILITY INSTALLATION PLAN CHECK Pian Check and Construction Inspections) $ TANK ID#(s): I PLAN CHECK FEE_$784/FACILITY REPAIR PLAN CHECK TANK ID#(s): $ TANK RETROFIT REPAIR FEE =$294/FACILITY use for monitoring equipment,s ill buckets,tank sumps,mist. PIPING REPAIR FEE _$294/FACILITY use for piping,under-dispenser containment,ed.)$ MISCELLANEOUS $ TRANSFER FEE _ $20 $ CONSULTATION FEE _ $98/HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $981 HOUR $ SAMPLING INSPECTION FEE = $98/HOUR ALL FEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK# I RECEIVED BY DATE RECEIVED SR EH 23 0321REVISED 08/3/07)