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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.sjgov.orF-/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ,A.Fcco * Go8xD J�►M tL tom. .a�t-t'y <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> ¢>5 1E. L,.o4-i►orp-S Ate/ (70M903. -%5t <br /> CITY <br /> tCITY STATE ZIP CODE #OF TANKS AT SITE <br /> F1 CA 'e'-)533 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ass-rrt. �-PLY�t t N C, . L t vPPy M CG W-S"7—t F <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> G7747 Gr s-rS-J 551. -1 sus <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> VVL,., .l I.I CQ. 5; + Closure ' stallation Repair Retrofit ::Z j p'T 6 3 <br /> ACTIVE FACILITY <br /> 2005 2006 2007 2008 2009 2010 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2005-2007) <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2008-2010) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK Is <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 Place <br /> TANK ID#(s): CLOSURE FEE=$366/TANK #TANKS X$366= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$366/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$976/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$366/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE _$366/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 <br /> CONSULTATION FEE _ $ 122/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $ 122/HOUR <br /> SAMPLING INSPECTION FEE _ $122/HOUR <br /> ALL FEES ARE BASED ON THE$122 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 07121/10) <br />