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SAN JOAQUIN COUNTY <br /> ENVIRONMEN-I'AI.,HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.s'=ov. r 7 ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> prrcjU 069090 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA C DE <br /> 85` E Lou L So 4 UL-e- -2-,a 't as- 91 L( <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA 533 v <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> U <br /> APPLICANT MAILING ADDRESV APPLICANT PHONE#WITH AREA CODE <br /> CITY ' 1 — STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> C/�' 5 Z�t 0 Closur slallatT n Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) 2002 2003 2004 2005 2006 2007 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008&New <br /> Installs as of 8/1/07) $ <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=$294/TANK #TANKS X$294= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$294/F CILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$784/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID# s : <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,spill buckets,tank 5umPs,misc.) $ ,�'/ <br /> PIPING REPAIR FEE =$294/FACILITY (use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $98/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR _ $ <br /> SAMPLING INSPECTION FEE = $98/HOUR $ <br /> ALL FEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQU�10 FACILI�ID AMOUNT RECEIVED CHECK# RECEI'ED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 08/3107) <br />