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' •.rlA t.A- 1 M{'A i {.t ' y i• iiyty�i�1� �ti�{.► t y 1 . y..+ V A y 11; _±e ;:',�.. I <br /> r <br /> �. SAN JQ,AQUIN COUNTY /CAU { <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone.•(209)468-3420 Fox:.(20,9)468-3433_Web,www.sigov.org/ebd <br /> FACILITY NAME FACILITY CONTACT NAME , <br /> I . <br /> 1 Y CW 1 ' c.Sup m <br /> FACILITY ADDRESS S TE PFIRONE#WITH AREA CODE <br /> t 12Z2 OCCY LAn �� �a • 3 <br /> CITYSTATE Z CODE .._. #OF TANKS AT SITE 1 <br /> CA T5216 <br /> i 3 <br /> { APPLICANT BILLING NAME APPLICANT C.QNTACT..NAME.... <br /> Eur CAT e �'S tpc' dam w tTf,� <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE j <br /> CITY STATE ZIP CODE__ CIRGLE:WORK T B .DO.NE - -CONTRACTOR ICC# ..__ <br /> �_ --- <br /> Ciosure Installation R air Retrofit <br /> I <br /> ACTIVE FACILITY <br /> 2006. 2007 2008 2009- 2010 2011 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2066-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2011) <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=$49.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): -CLOSURE FEE--$375/TANK #TANKS X$375= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$1,000/FACILITY <br /> RLP IR PLAN CHECK <br /> TANK,ID <br /> —" �TANK RETROFIT REPAIR FEE $375/Fl1CILITY (use for monitoring equipment,cold starts,EVR upgrades, �- <br /> s ill buckets sums misc.) � <br /> PIPING REPAIR'FEE=$3751 FACILITY use for 0101fig,under-dispenser 6ontalnment,eat. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 <br /> _ .CONULTAi`I©N'-FEE 125/HOUR <br /> UNAUTHORIZED`RELEAS'E•EVALUA°CION PEE = $126/HOUR $ <br /> SAMPLINGINSPECTION.FEE = 125/HOUR <br /> ALLFEES-ARE BASEDON-THE-$125-HOURL-Y-HATE;-TIME'THAT EXCEEDS"PE 8 D WILL BE BILLED TO APPLICANT. <br /> TOTA4AMOUNT DUE $ <br /> OFFICL°_USE-ONLY .. <br /> S RVICE.RfiQUEST# - FACILITY"ID T-""' WOUNYVEIVED--- -CHECK#- - -DECEIVED BY DATE RECEIVED <br /> EH 23:032 IREVIS0 0811111 by KF) <br />