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SAN JOAQUIN COUNTY 4 <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.or /g ehd <br />RECE VED <br />MAY 2 2008 <br />FACILITY NAME <br />FACILITY CONTACT NAME JO <br />A <br />LowIV\Ei�C�R1�I OSS I �� )_ <br />IVI�1.jb �I Q A HEALTHpNMENTAI,. <br />PArjRdeNr <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />975 SCSIV1I VPr,RMC) IJr KVE <br />,Q09 334 - 341I <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />LbD1 <br />CA <br />q5940 <br />$ <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />ASuL" Wlus(31.1 <br />APPLICANT PHONE # WITH AREA CODE <br />APPLICANT MAILING ADDRESS <br />(-,150 OKE ,tJ R"e A RC)P D <br />530 56-1- 6a91 <br />CITY STATE ZIP CODE <br />CIRCLE WORK TO BE DONECONTRACTOR <br />ICC # <br />t� C Cp, 115 <br />Closure nstallatio � Repair Retrofit <br />PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect. <br />ACTIVE FACILITY <br />TANK ID # s <br />CLOSURE FEE= $294 /TANK <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$ <br />PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect. <br />$ <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) <br />$ <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 <br />CLOSURE FEE= $294 /TANK <br /># TANKS X $294 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />INSTALLATION PLAN <br />(Plan Check and Const <br />TANK ID # (s) : <br />PLAN CHECK FEE = $784 / FACILITY <br />REPAIR PLAN CHECK <br />I <br />TANK ID # (s) : <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, misc. <br />$ <br />PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 98/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />ALL "hb AKL bAbLU UN I r- ab6 NUUKLT KA I C. I IMC 1 PIA 1 cm rrUA rCCJ PAID YYILL OC OILLCU I U APPLIt AN I. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY I DATE RECEIVED <br />SR®0J6' /97 An, <br />EH 23 032 (REVISED 12/31/07) <br />