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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, ov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />0 L w► P ( A-,-( "k f-1 i '�- <br />m ( C 61 A - Pit W4 [,-red <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />3 3 0 0 (/tl' i'•�-T �.fz-Loo (Z � - <br />2006 <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />S T -o C l/- T-0-4 <br />CA <br />9 S-0 0.5- <br />3 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />W A LTOtk <br />m ( C 61 A - Pit W4 [,-red <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />1P.C. BoK lo2S� <br />2006 <br />CITY STATE ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />1 . 1 S -� C A �`6 9 ( <br />Closure Installation epair)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 />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />e� ou cn Tn AODI If -AMT <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK ( x : >> <br />$ <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 CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : PLAN CHECK FEE = $784 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : $ <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc. <br />$ <br />PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect.) Z <br />MISCELLANEOUS <br />$ <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 />e� ou cn Tn AODI If -AMT <br />ALL rr=- AMC 6A0Cu vn <br />� ^n I ICC AAII V <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 0813107) <br />