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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPAR <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />/ <br />��I � r P�'?CC�► �/tfliJr(9'1'i <br />�� <br />FACILITY ADDRESS <br />I SITE PHOI9E # WITH AREA CODE <br />3o 1 u> (S4fte <br />Jo? 3Cos - <br />CITY I STATE <br />ZIP CODE # OF TANKS <br />CA <br />,, (( <br />J a ` o <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />P +f- l r% + v.c, <br />Ce C'rri e. <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />i4�,f - 633 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRA <br />/S�2l?S <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) 2002 2003 2004 2005 2006 2007 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />Installs as of 8/1/07) <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = S15 / TAMC <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY Is <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): CLOSURE FEE _$294 / TANK # TANKS X $294 <br />TEMPORARY CLOSURE <br />Ian Review and Inspections) <br />TANK ID # (s) : TEMPORARY CLOSURE FEE _ $294 / FACILITY $ <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : PLAN CHECK FEE _ $784 / FACILITY $ <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE _ $294 / FACILITY use for monitoring equipment, spill buckets, tank sum ,misc. $i 10 <br />PIPING REPAIR FEE = $294 / FACILITY use for i in ,under -cis enser containment, ect $ <br />■RlCfGi 1 A\IC/1In __ <br />EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />'ICE USE ONLY <br />ACE REQUEST # FACILITY ID AMOUNT RECEIVED' --CHECK # RECEIVED BY DATE RECEIVE <br />1032 (REVISED 08!3!071 <br />TRANSFER FEE _ $ 20 <br />$ <br />'CONSULTATION FEE _ $ 98/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 98 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />ALL FEES ARE BASED ON THE $98 HOURLY RATE TIME THAT <br />$ <br />- <br />EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />'ICE USE ONLY <br />ACE REQUEST # FACILITY ID AMOUNT RECEIVED' --CHECK # RECEIVED BY DATE RECEIVE <br />1032 (REVISED 08!3!071 <br />