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SAN JOAQUIN COUNTY <br /> ENviRONMENTAL HEALTH DEPARTMEffi <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 F=(209)469-3433 Web:www. Ww-ov chd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> "+�' GEi✓E�L ofP/d�L �I'l�,r <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> .zr,>,o /3:'fdn4-/o o4anc .may 'Z6,- Poo <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Lol02 Closure Installation Repair etro SZ9"9/•-�1 <br /> ACTIVE FACILITY <br /> 2003 20134 2005 2006 2007 2008 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK C')G" <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 COPA PROGRAM=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$2941 TANK #TANKS X$294= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$294/FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$7841 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE = /FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,mise. <br /> PIPING REPAIR FEE _$294/FACILITY (use for piping,under-dispenser containment,ect_) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $; OUR pro <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR $ <br /> SAMPLING INSPECTION FEE _ �9W HOUR $ <br /> ALL FEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED CHECK# 1 RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 12131107) <br />