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• • <br />RECEIVED <br />� SAN JOAQUIN COUNTY , L „ � � 014 <br />ENVIRONMENTAL HEALTH DEPARTMENT ` <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Wei): www.siQov.o 1RONMEN-FAL HEALTH <br />FACILITY NAME <br />FAGILI I T cvN I Ac i NAma —; r <br />. � /"O /Li <br />s <br />V t /e�2.-""142a A. - <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />zN; 5� f '�-'e'qC ? � °//, �1LI — �c ,, <br />CITY <br />I STATE ZIP CODE # OF TANKS AT SITE <br />Z �� <br />CA,,-/, <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />CLOSURE FEE = $375 /TANK <br />2008 2009 <br />c 1, YL I' C <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2012 <br />2013 <br />u A- <br />STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />$ <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # s <br />CLOSURE FEE = $375 /TANK <br />2008 2009 <br />2010 <br />2011 <br />2012 <br />2013 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) <br />$ <br />PIPING REPAIR FEE = -375 / FACILITY use for piping, under -dispenser containment, ect. <br />SAMPLING INSPECTIG'! FEE _ $ 125/ HOUR <br />ANT - <br />$ <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = S15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY !N A CUPA PROGRAM =$35.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitte l' C,: sure in Place <br />TANK ID # s <br />CLOSURE FEE = $375 /TANK <br />#TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />kLLATION PLAN CHECK <br />Check and Construction Ir <br />TANK ID # <br />PLAN CHECK FEE = $1000 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TRANSFER FEE _ S25 <br />$ <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cck.I starts, EVR upgrades, <br />$ <br />spill buckets, su nns, mist. <br />$ <br />PIPING REPAIR FEE = -375 / FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ S25 <br />$ <br />CONSULTATION FEE = S 125/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />SAMPLING INSPECTIG'! FEE _ $ 125/ HOUR <br />ANT - <br />ALL rcca Amc PAa-- <br />TOTAL AMOUNT DUE $ <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED I CHECK #- RECEIVED BY I DATE RECEIVED <br />FH 23 312 IREVI` _ ; R <br />EH 2303-V>ZEVibti - <br />