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SAN JOAQUIN COUNTY 401 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj,-ov.or /Q ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />"TV- S`k.P-� �- <br />L C`tl -t <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />6 <br />2007 <br />CITY STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />--'r`'6-0-14 <br />s -e <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />sew 0 Z <br />V 'V -t VLI w <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />6 <br />2007 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />s -e <br />, f;,- <br />Closure Installation (Sii Retrofit <br />vzz <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $294 / TANK <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$ <br />PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <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 = $294 / TANK <br /># TANKS X $294 = <br />TEMPORARY CLOSURE <br />Plan.Review.and Inspections)... .. <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE _ $294 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : <br />I PLAN CHECK FEE = $784 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TRANSFER FEE _ $ 20 <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, misc.)II <br />$ <br />PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS- <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 98/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 /HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />ALL t-tt5 AKt CAbLU LIN I tit 4,56 ML)UKLT KAI L. I IMt I MAI tALttUJ I-ttb MAID WILL tit CILLtU I V ANI'LIL.AN I. <br />OFFICE USE ONLY <br />-91 <br />