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SAN JOAQUIN CotTNTY 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, 3"'Floor.Stock-ton. CA 95202-2708 <br /> 0, Telephone:(209)468-3420 Fax(r floor):(209)468-3433 Web:ivNV\v.sjgov.or6,/el1d <br /> FACILITY NAME FACILITY CONTACT NAME <br /> S,Te- P(AfSi-re- UXAV-SA�9- RA" AJ DfkT,1 tylo- O—Awks <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> % 6 10 F— , %A q-,K (2ADq) —310& <br /> CITY STATE 23P CODE #OF TANKS AT SITE <br /> S-r CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> BA&t—sy Ey <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> a?0 M A Cw 6= CXIW—L F—j <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> LD (A Q!5-Z4o Cimm Installation Repair etro 1452 4-4,q 08 <br /> ACTIVE FACILITY <br /> 2000 2001 2002 2003 2004 2005 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK <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=$24.00t FACILITY <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279 <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$279 FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspecfions) <br /> TANK ID#(s): PLAN CHECK FEE=$744 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY (use for monitorkV equipment,spill buckets,tank sumps,misc.) <br /> PIPING REPAIR FEE $2791 FACILITY (use for piping,under-dispenser cordainment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE $20 <br /> CONSULTATION FEE $931 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE $93/ UR <br /> SAMPLING INSPECTION FEE $93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID VWLL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# ILrTY 10 AMOUNT RECEFVED CHECK# RECEIVED B DATE RECEIVED <br /> SR 1: j <br /> EH 23 032(REVISED 0Z22(06) <br />