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Jul 07 06 09: 43a Jeffrey C. Henley 714-739-1499 p. 3 <br /> SAM JOAQUIN COUNTY <br /> ENv)RONMENTAL HEALTH DEPARTMENT <br /> • 304 East Weber Avenue,3`d Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(.5*floor):(209)468-3433 Web:www.sipov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 3e-4 -Z'S —as..o. �---e a_`a a� r�l f5 `.t`-f 1 -4pt 13 <br /> CITY STATE ZIP CODE OF TANKS AT SITE <br /> CA �'r S 7 C= 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 4-z-O I Iti t 2k —,5 1 "-'f-C7 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICG# <br /> 'tClosure Installation 200Retrofit <br /> ACTIVE FACILITY <br /> 2000 2001 2002 2003 2004 2005 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and In ons <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$2791 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK 10#(s): PLAN CHECK FEE_$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID IRs <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment.s ill buckets,tank sumps,misa $Z <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dislmnser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR $ <br /> SAMPLING INSPECTION FEE = $931 HOUR $ <br /> ALL FEES ARE BASED ON THE$83 HOURLY RATE. TIME THAT EXCEEDS FEES PIVD WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REWEW*=T FACILRY ID 1 AMOUNT RECEIVED CHECK# BY LDATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 0212Z" <br />