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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.or /g ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Cryur)f 76 <br />ky-af- <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />s, Court C-1�� ��� <br />26� �'3a1367 <br />CITY STATE <br />I ZIP CODE # OF TANKS AT SITE <br />S� CA&A0 rl CA <br />CIRCLE WORK TO BE ONE CONTRACTOR ICC # <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />e i l— ral l el(It t4-191,-e-rl <br />A-e`i5" uJ <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />f 7lp ���4/ 'GSA <br />`71� �t7Ca� <br />CITYSTATE <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) <br />ZIP CODE <br />CIRCLE WORK TO BE ONE CONTRACTOR ICC # <br />tSy ;moi <br />Closure Installation etrofit Z - <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br />2008 <br />2009 <br />2010 <br />2011 <br />2012 <br />2013 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 1251 HOUR <br />$= <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br /># TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />INSTALLATION <br />(Plan Check and <br />TANK ID#(s): <br />PLAN CHECK FEE = $1000 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID#(s): <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />TRANSFER FEE _ $ 25 <br />spill buckets, sumps, misc. <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 1251 HOUR <br />$= <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED w ArrUV. -' I. <br />TOTAL AMOUNT DUE $ <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID 7 AMOUNT RECEIVED CHECK # RECEIVED BYDATE RECEIVED <br />EH 23 032 (REVISED 1/16/2013 by KF) <br />