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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH RTME141 <br />last Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (54floor): (209) 468-3433 Web: www.sil ov.or ehd <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />FACILITY ADDRESS <br />le <br />V L C oat <br />SITE PHONE # WITH AREA CODE <br />CITY <br />STATE <br />ZIP CODE <br />CITY <br />O_ V, 05 <br />STATE <br />ZIP CODE # OF TANKS AT SITE <br />Closure Installation Repair Retrofit: j l) S a -t 9 t o <br />CA <br />q <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />`C C!l 54-5 5 LSC., <br />APPLICANT MAILING ADDRESS <br />$ <br />APPLICANT PHONE #WITH AREA CODE <br />2001 <br />2002 <br />CITY <br />STATE <br />ZIP CODE <br />. ....... .. . <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC A. <br />O_ V, 05 <br />Cb <br />�(( <br />Closure Installation Repair Retrofit: j l) S a -t 9 t o <br />ACTIVE FACILITY <br />TANK ID # s : CLOSURE FEE = $279 !TANK # TANKS X $279 = <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />2005 <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />$ <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 />Pian Review and ins ctions .. 1 <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE _ $2791 FACILITY <br />n Check and <br />TANK ID # <br />PLAN CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # s <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring a ui ment, spill buckets, tank sum s, mise. $ 1 <br />PIPING REPAIR FEE = $279 / FACILITY use for DiDina. under-dis enser containment, act. $ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 931 HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />ALL FEES ARE BASED ON THE 593 HOURLY RATE. TIME <br />$ <br />34 <br />