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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.or /g ehd FACILITY NAME FACILITY CONTACT NAME tyNG-r(,1— L O4( V FACILITY ADDRESS SITE PHONE # WITH AREA CODE D 7 0 067) -173— 7337 CITY I STATE ZIP CODE # OF TANKS AT SITE H u& - 93k -2J, 3 CA 4 3 APPLICANT BILLING NAME TANK ID # (s): APPLICANT CONTACT NAME 2004 2005 APPLICANT MAILING ADDRESSr 2007 APPLICANT PHONE # WITH AREA CODE �. H u& - 93k -2J, 3 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # �J G �/ a Closure Installatio Repai Retrofit ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $345 / TANK 2004 2005 2006 2007 2008 2009 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) $ PIPING REPAIR FEE = $345 / FACILITY use for piping, under-dis enser containment, act. $ SAMPLING INSPECTION FEE = $ 115/ HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $15 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $345 / TANK # TANKS X $345 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE= $345 / FACILITY REPAIR PLAN CHECK TANK ID # (s) : TRANSFER FEE _ $ 20 TANK RETROFIT REPAIR FEE = $345 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $ spill buckets sumps, misc. $ PIPING REPAIR FEE = $345 / FACILITY use for piping, under-dis enser containment, act. MISCELLANEOUS TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 1151 HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR $ SAMPLING INSPECTION FEE = $ 115/ HOUR ALL FEES ARE BASED ON THE $115 HOURLY RATE, l IME 1HA1 EJCGEEUS Ptts rA1u well of nFllcu w r�rru�.�an �.