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SAN JOAQUIIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTME <br />304 East Weber Avenue, 3'd Floor, Stockton, CA 95202-2708 <br />Telephone. (209)468-3420Fax (5"'floor): (309)468-3433 Web: www _s.gov- go'ehd I <br />(J <br />FACILITY <br />FACILITY CONTACT NAME <br />yNAME <br />APPLICANT CONTACT <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />2003 <br />3311-3x33 <br />CITY <br />I STATE <br />ZIP CODE <br />I # OF TANKS AT SITE <br />I 'p --j .' <br />I CA <br />Sa y2 <br />1 2 <br />APPLICANT BILLING NAME <br />TANK ID # (s): <br />CLOSURE FEE = $279 / TANK <br />APPLICANT CONTACT <br />2001 <br />2002 <br />2003 <br />NAME <br />APPLICANT MAILING ADDRESS <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />APPLICANT PHONE # WITH AREA CODE <br />13a) lv- �lr-�l/z <br />t�„� <br />0 3x33 <br />CITY <br />$125 PER TANK AFTER FIRST TANK <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />1 ham' <br />L <br />Cls�yr� <br />Closure Installation Repair Retrofit <br />Say�D� - GfG <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $279 / TANK <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />2005 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />$ <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 = $279 / TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />ALLATION PLAN CHECK <br />Check and Construction Ir <br />TANK ID # (s) : <br />PLAN CHECK FEE = <br />H <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, mist.) <br />Q <br />PIPING REPAIR FEE = $279 / FACILITY (use for pipWg, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # 11 ACILITY ID AMOUNT RECEIVED I CHECK # RECEIVED BY I DATE RECEIVED <br />SR <br />EH 23 032 (REVISED OW22RIM <br />