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SAN JOAQUINi'COUNTY,/ <br />ENVIRONMENTAL HEALTH DEPAR ol'V <br />600 East Main Street, Stockton, CA 95202-3029 - <br />Telephone. (209) 46 8-3 420 Fax: (209) 45 8 -3 43 3 Web: wwws' ov- omy/el id <br />FACILITY NAME <br />I <br />F CILITY CONTACT N E <br />TEMPORA Y CLOSURE <br />Rev,and lns actions <br />TANK ID # (s) : <br />Flan Check, nd Construction In actions - <br />FACILI ADDRESS <br />$ TE PHONE # WIT AREA CODE' <br />M151 n,� <br />STATE <br />ZIP CODE # F TANKS AT SITE <br />CA; <br />APPLICANT BILLING NAME <br />A 3PLICANT CONTACTAME <br />E T ac1 p -ac, �,iu, <br />t4AM vJ" <br />APPLICANT MAILING ADDRESS <br />A PLICANT PHONE # W TH-AREA ODE <br />--- __ - __ _........ Pg _._. _ <br />TANK RETROFIT REPAIR FEE $375 / FACILITY (use for monitonng quipmen cold starts R u rad' s, <br />s II buck is sum s meso <br />CITY STATE ZI CODE <br />CIRCLE WORK TO B DONE CONTRACTOR ICC # <br />PIPING REPAIR FEE _ $375 / FACILITY use for pipft. unde -dispenser containmentt act. <br />CI sure Installation"- e 1 Retrofit <br />a <br />ACTIVE FACILITY <br />20061 2007 2008 2009 20 0 2011 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) <br />$,550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) <br />$,125 PER TANK AFTER FIRST TANK I $ <br />TANK PENALTY ASSESSED $ <br />TANK SURCHARGE _ $15 / TANK. $ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTOEX IN A CUPA PROGRAM $49.00/ F kCILITY $ <br />PERMANENT CLOSURE <br />Removaj or Permitted Closure in Place) <br />TANK ID # s CLOSURE FEE _ $376 / TANK ! # TANK X $375 <br />TEMPORA Y CLOSURE <br />Rev,and lns actions <br />TANK ID # (s) : <br />Flan Check, nd Construction In actions - <br />TEMPORAR CLOSURE FEE _ $37 /. FACILI <br />INSTALLATION PLAN CHECK <br />Flan Check, nd Construction In actions - <br />T. <br />ANK ID # (s) : <br />PLAN CHECK FEE _ $1,0d0 / FACILIITY- <br />REPAIRKLAN CHECK <br />TANK ID # (s) <br />-- -- <br />--- __ - __ _........ Pg _._. _ <br />TANK RETROFIT REPAIR FEE $375 / FACILITY (use for monitonng quipmen cold starts R u rad' s, <br />s II buck is sum s meso <br />PIPING REPAIR FEE _ $375 / FACILITY use for pipft. unde -dispenser containmentt act. <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE '.: _ V>.4 <br />CONSULTATION FEE-=$125/HOUR- <br />UNAUTHORIZED RELEASE EVALUATION FEE = $125 / HOUR <br />SAMPLING INSPECTION FEE i$ 125/ HOUR <br />ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME -THAT EXCEEDS FE S PAID WILL BE BILLED TO APPLICA T. <br />TOTAL AMOUNT DUE <br />O0FICE U` E O LY <br />$ <br />SERV ICE R 4 EST # ` ' FACILITY 1D AMOUNT RECEIVED HE K # ECEIVED B <br />DATE RECEIVED <br />EH 23 032 (REVISED 08/1/11 by KF) <br />I i . <br />i <br />' I <br />f <br />4 <br />