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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 FACILITY CONTACT NAME <br /> of '5fbmhoIRiwjl <br /> FACILITYAnnRPec SITE PHONE WIT AREA CODE <br /> UITY 1 S1rATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICfNT ENLUNG NAME 4 APPLIC NT jCONTACT NAME <br /> i C( ' o ! <br /> APPVCA MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> -,?j- i aalmori -60331 <br /> CITY U ST E ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> , t � Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2003 2004 2005 2006 2007 2008 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) <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): CLOSURE FEE=$315/TANK #TANKS X$315= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$315/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$840/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> 11 9 spill buckets,sumps,misc. <br /> PIPING REPAIR FEE = CILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $105/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $105/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE = $105/HOUR <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 7/18/08) <br />