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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.sj o, v.or /g ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />APPLICANT CONTACT NAME <br />be ESS �- <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />444 M®sy)(&,4o <br />z15l <br />CITY <br />1-/4 <br />STATE <br />CA <br />ZIP CODE <br />T'533J- IR747 <br /># OF TANKS AT SITE <br />► 5fl"+33 e®M?�Pqv <br />APPLICANT BILLING NAME <br />Removal or Permitted Closure in Place <br />APPLICANT CONTACT NAME <br />be ESS �- <br />2004 <br />-411 TaYhQS <br />APPLICANT MAILING ADDRESS <br />2007 <br />APPLICANT PHONE #WITH AREA CODE <br />2 �-v �2� <br />PIPING REPAIR FEE = $294 / FACILITY use for piping, under -dispenser containment, ect. <br />7/ o- 3 � <br />CITY <br />STATE ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />La ® <br />C�8 <br />Closure Installation Rep ' Retrofi <br />1 <br />ACTIVE FACILITY <br />Removal or Permitted Closure in Place <br />TANK ID # (s) : <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />PIPING REPAIR FEE = $294 / FACILITY use for piping, under -dispenser containment, ect. <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />$ <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s) : <br />$ <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />TANK ID # (s): <br />CLOSURE FEE = $294 /TANK <br /># TANKS X $294 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />PIPING REPAIR FEE = $294 / FACILITY use for piping, under -dispenser containment, ect. <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />INSTALLATION PLAN <br />(Plan Check and Const <br />TANK ID # (s) ' I PLAN CHECK FEE = $784 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />315 0D <br />spill buckets, sumps, misc. <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />-$ <br />PIPING REPAIR FEE = $294 / FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 98/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />-$ <br />SAMPLING INSPECTION FEE = $ 98/ HOUR <br />none ecce oAin WII 1 RF RII I FO TO APPLICANT. <br />ALL FEES ARE BA5ED oro 1 Ht;OW HUUMLi MAI o. "mc a ... <br />OFFICE USE UNL7 <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 12131107) <br />