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• <br />SAN .10AQt [IN ('OUNI'1' <br />I NVIRONMIiN7'AI.IIFAL'I'II I)EPAR'fMI-'N'f <br />600 East Main Street, Stockton, C'A 95202-3029 <br />7'dephm/e: (209) 468-3420 hix: (209) 468-3433 FVeb: ",w _sjggv.�rg/ch_�i. <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />_ <br />'Teso" V S4 --4c. g 15 <br />r ►�., �N c�- 4MA,,tw1f*1 a <br />FACILITY ADDRESS <br />_ _T�+�..s,�R.o <br />SITE PHONE # WITH AREA CODE _ <br />14m lv r <br />A -210 6 & 2-2L' <br />CITY <br />STATE <br />ZIP CODE <br />I # OF TANKS AT SITE <br />"t-1 <br />CA <br />'i S2-tlo <br />$ <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />k k S r:v(A ww-aa, N % <br />N -%-v 1 Ar'q0. GrUA osa- [ <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />Sir+c. I:l bw►.? MD. gme.*R" <br />( GG -1) 2-so-"'t3C)0 <br />-W- <br />CITY <br />STA E <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC <br />$ <br />Closure Installation Re air etrofil <br />'/ "C - <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 />$500 FEE INCLUDES FACILITY FEE 4 1 TANK (2007-2008) <br />$ <br />PIPING REPAIR FEE. = $375 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = S15/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 />TEMPORARY CLOSURE FEE = $3751 FACILITY <br />INSTALLATION PLAN CHECK <br />{Plan Check and Construction Ir <br />TANK ID # <br />PLAN CHECK FEE = $1000 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TRANSFER FEE _ $ 25 <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps. mise. <br />$ <br />PIPING REPAIR FEE. = $375 / FACILITY (use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />ALL PCkS AKE BASED UN THE $1Z5 HOURLY RATE. TIME I HAi EAGEEUS YEES 1'AIU WILL tIL UILLtU IU AF-rLR.AN I. <br />TOTAL AMOUNT DUE I $ <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 04/13/12 by KF) <br />