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• <br />r� <br />U <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www;sjgq_v_.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />a v tv. s -ro a z �( <br />.c . YM ( C w At -t -t, WA-C;T0-4 <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />t4- vin A, 1 u s r - <br />It 6 3--3—((S`2-- <br />CITY <br />I STATE <br />I ZIP CODE <br /># OF TANKS AT SITE <br />m A -4-T" E C A <br />CA I <br />4 S-3 3 (0 <br />3 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />w A L' w.c , <br />.c . YM ( C w At -t -t, WA-C;T0-4 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />- <br />P.p, gp)( 10-r <br />It 6 3--3—((S`2-- <br />CITY I STATE <br />ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />W , S � - C q, <br />9 5'6 q ( Closure Installation Repai Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $294 / TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 98 / HOUR <br />SAMPLING INSPECTION FEE <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2'008. & New <br />$ <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 = $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 CHEC <br />(Plan Check and Construction <br />TANK ID # <br />CHECK FEE = $784 / FACILITY <br />R <br />REPAIR PLAN CHECK <br />TANK ID # s <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY use for monitoring equipment, spill buckets, tank sumps, misc.) <br />PIPING REPAIR FEE = $2941 FACILITY (use for piping, under -dispenser containment, ect.) <br />c <br />Z <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 98/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 98 / HOUR <br />SAMPLING INSPECTION FEE <br />ALL ht=3 AKC DAJ=U UN 1 nm iPao nw—I -n I — , ung -'— . --- .—......__ <br />OFFICE LISP ONLY <br />SERVICE REQUEST # FACILITY ID I AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 08/3/07) <br />