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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.siog vorg/ehd FACILITY NAME FACILITY CONTACT NAME eoaal"- C!ub 7!o 14vLL-f Itr FACILITY ADDRESS SITE PHONE#WITH AREA CODE o7,5-7S (ear)-la L%,4,6 $/ --2e9) '7 CITYI STATE I ZIP CODE I #OF TANKS AT SITE CA I 11� 6'2-1)f APPLICANT BILLING NAME APPLICANT CONTACT NAME eet-24red Pe-taleif h"-- 1-l41.6leen /4ein /ACL cJ APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE If CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# Pk a/9- .n1 I C- Closure Installation RE2 Retrofit ACTIVE FACILITY 2006 2007 2008 2009 2010 2011 $500 FEE INCLUDES FACILITY FEE+1 TANK(2006-2007) $550 FEE INCLUDES FACILITY FEE+1 TANK(20G8 20,1 1) $ $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED $ TANK SURCHARGE=$15/TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID#(s): CLOSURE FEE=$366/TANK #TANKS X$366= TEMPORARY CLOSURE Plan Review and Inspections) $ TANK ID#(s): TEMPORARY CLOSURE FEE=$366/FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID#(s): I PLAN CHECK FEE=$976/FACILITY REPAIR PLAN CHECK TANK ID#(s): $ TANK RETROFIT REPAIR FEE =$366/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, spill buckets,sumps,misc. $ PIPING REPAIR FEE _$366/FACILITY use for piping,under-dispenser containment,ect.) MISCELLANEOUS TRANSFER FEE _ $25 $ CONSULTATION FEE = $122/HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $122/HOUR $ SAMPLING INSPECTION FEE = $122/HOUR $ ALL FEES ARE BASED ON THE$122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. TOTAL AMOUNT DUE $3lPln OFFICE USE ONLY SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED EH 23 032(REVISED 06/3111 by KF)