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SAN JOAQt4N COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3`d Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fox(S`"floor):(209)468-3433 Web:www.sjgov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ,At2-6-0 z%rk ('O 80 ¢.O--r SSE i <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> �G 8t8 "tet 1 -9`h \3 <br /> CITY STATE t ZIP CODE #OF TANKS AT SITE <br /> CA �5-3 'S o 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> --Ac a-co c�ur ic' <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 1 I C)G 'E31%2-4D-Aa ,... , e-% U I -5\ 3 C1 % 4-o <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> q�3It` Closure Installation Repair etrofit sZSZoS"�-v� <br /> ACTIVE FACILITY <br /> 2000 2001 2002 2003 2004 2005 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK <br /> $125 PER TANK AFTER FIRST TANK <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=$279/TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY (use for monitoring equipment,spill buckets,to k sumps,misc. <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping,under-dispenser containment,ecI. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $93/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR <br /> SAMPLING INSPECTION FEE _ $93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02/22/05) <br />