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WSAN JOAQUIN COUNTY <br /> IRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3`d Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(51h floor):(209)468-3433 Web:www.sjgov.or¢/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> A01 WV-0_rak <br /> 6q ) 173 -13317 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> O J-13.� f� <br /> CITY STATE. ZIP.COBE.. CIRCLE WORK TO.BE DONE.: . CONTRACTOR ICC#, <br /> / Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2002 2003 2004 2005 2006 2007 <br /> $500 FEE INCLUDES FACILITY FEE+1 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=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE_$285/TANK #TANKS X$285= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANKTEMPORARY CLOSURE FEE_$285!FACILITY $" <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$760/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$285!FACILITY use for monitoring equipment,s ill buckets;tank sumps,misc. $ <br /> PIPING REPAIR FEE _$285/FACILITY use for piping,under-disenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $95/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $95/HOUR $ <br /> SAMPLING INSPECTION FEE _ $95/HOUR $ <br /> ALL FEES ARE BASED ON THE$95 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 /> SIR <br /> EH 23 032(REVISED 01/29/07) <br />