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n <br />11 <br />SAN JOA01AN COUNTY <br />1 NVIRONMENTA I, f IEALTII DEPARTMIiN'I" <br />600 Last Main Strect, Stockton, (."A 952112-3029 <br />7'dej) ow: (209) 468-3=120 / a.y. (209) 468-3431 l eb: wwv sjc ov.grg/g tai <br />FACILETY NAME <br />FACILITY CONTACT NAME <br />��.3 AG1s1 I1 Si�i-�'� ttf 15 ._....__�._ <br />1�r ►t�.► eN G- Nf IG:s'L tom. <br />FACILITY ADDRESS <br />_�4�..-_S.�iL� _ __ <br />_ SITE PHONE # WITH AREA CODE V <br />14m Gas <br />d 6 2...r.- 6 22.x" <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />tCITY <br />iw,,o p I <br />`t _ <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />pA <br />k- ik S 1:!4j(% twors ! elle N t, <br />Df -v m ($'k" �P�Pki>tx 'CX^ <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />&NaS SAN P "wtxw ` <br />G_ ) 2 -To --�1` 0 0 <br />CITY <br />STATE <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICG # <br />`t _ <br />_ Closure Installation Re air etrofit <br />ACTIVE FACILITY <br />TANK ID # s <br />CLOSURE FEE = $375 / TANK <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />2012 <br />$ <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK {2007-2008} <br />PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) <br />1 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009.2012) <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # s <br />CLOSURE FEE = $375 / TANK <br /># TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : _ <br />i"EMPORARY CLOSURE FEF_ = $375 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction In <br />TANK ID # <br />PLAN CHECK FEE = $1000 / FACILITY <br />REPAIR PLAN CHECK <br />TANK €D # (s} <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps. misc. <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />$ <br />ALL rttS AKt t3ASELJ ON THE 5125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE Is <br />