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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(Sri`floor):(209)468-3433 Web:www.si og v_or ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Uaocpdr <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 27v> 20 � 'l3. <br /> CITY I STATE ZIP CODE <br /> S� I #OF TANKS AT SITE <br /> CA o0.7 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAMES <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> A�10 awno 01-99-7/Z <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> C OIS//�i Closure Installation epa' Retrofit 5-5 <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 2001 2002 2003 2004 1 2005 2006 <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 /> TANK ID#(s): TEMPORARY 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 /> S7• 33 <br /> $ <br /> TANK RETROFIT REPAIR FEE =$ /FACILITY use for monitoring equipment,s ill buckets,tank sumps,misc. <br /> PIPING REPAIR FEE _$285/FACILITY use for piping,under-dispenser 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$SS HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK# RECEIVED BY DATE RECEIVED <br /> SR I L <br /> EH 23 032(REVISED 07/28/08) <br />