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SAN JOAQUIN COUNTY <br />NVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (5'h floor): (209) 468-3433 Web: www.si-gov.org/ehd <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />i9 cS 1F <br />lIA G <br />c l VACOOt <br />FACILITY ADDRESS <br />2004 <br />SITE PHONE # WITH AREA <br />STATE <br />ppp <br />\` <br />yCODE <br />ii VVtt 44 <br />CITY <br />STATE <br />ZIP CODE # OF TANKS AT SITE <br />1 <br />$125 PER TANK AFTER FIRST TANK <br />CA <br />76 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />-, S JHCI—V±j(K�+(XWaA <br />2000 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2003 <br />2004 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />® <br />, <br />Closure Installation epai Retrofit <br />$125 PER TANK AFTER FIRST TANK <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $279 / TANK <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />2005 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />UNAUTHORIZED RELEASE EVALUATION FEE =$93/HOUR <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$125 PER TANK AFTER FIRST TANK <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 = $279 / TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />INET <br />Check and <br />TANK ID # (s) : I PLAN CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # s <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, s ill buckets, tank sumps, misc.) <br />PIPING REPAIR FEE = $279 / FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS . <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE =$93/HOUR <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEW FEES FAA m of bm- aw w nrrua iv <br />