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,.6►Y M}e 1.}f-a 1t P!1 a s !t } Y ! ! Y} pe '.Y�'Y,.�Yt'f�f,�' t}.pp �i � <br /> Mil.- OPW <br /> a <br /> L � Y S'�6t.. M � 1 t •Ici¢l. F F <br /> • SAN JQAQiTIN COUNTY 1 <br /> { ENVIRONMENTAL HEAI;TR DEPARTMENT <br /> 600 Bast Main Street,Stockton,CA 95202-3029 1 <br /> ! Telephone:(209)468-3420 Fax:(2qs)468-3433 Web:MMM-sj&ov.org/qhd a !' <br /> r t e <br /> FACILITY NAME FACILITY CONTACT NAME <br /> i _ } <br /> FACILITY ArJDRESS SITE PHO E#WI H ARE-A`CODE <br /> �12-12- <br /> CITY STATE 2IP CODE <br /> #OF TANKS —SITE } <br /> CA <br /> r <br /> APPLICANT BILLING NAME APPLICANT CONTACT Y LAME <br /> Lnc,v Nit r'rl W"CTf-..,� <br /> APPLICANT MAILING AbDRESS APPLICANT PHONE*WITH AREA CODE <br /> W, 5TOV <br /> CITY <br /> STATE ZIP CODE ___StRCLE;WQRK_TO B -DONE . •.-...CONTRACTOR ICC.# <br /> Closure Installation Re air Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2066-2007) 2006 2007 2008 2009 2010 2011 <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/ <br /> TCLOSURE TANK #'TANKS X$375_ $ <br /> EMPORARY <br /> Pian Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Pian Check and Construction Inspections) <br /> TANK ID#(s): $ <br /> PLAN CHECK FEE_$1,000/FACILITY <br /> REPAIR PLAN CHEC—K <br /> TANK ID#(s) <br /> - =$ <br /> TANK RETROFIT REPAIR FEE --' --- <br /> $375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades--- <br /> "ill buckets sumps,m}sc. <br /> PIPING REPAIR FEE $375/FACILITY use for"i iri ,under-dispenser containment,ect, $ <br /> MISCELLANEOUS <br /> TRANSFER FEE <br /> tNSULTATION FEE _.._.. <br /> $125/IiOUR <br /> UNAUTHORIZED-RELEASE'EVALUATION'FEE _ $12b/HOUR <br /> _ -- ---- .... <br /> SAMPLING INSPECTION FCE <br /> - $125/HOUR $ <br /> ALLFEES-ARE BASED UN THE$12b HOURLY RATE TIME'THAT EXCEEDS FEESLAID WILL SE BILLED TO APPLICANT. <br /> TOTAL,AMOUNT DUE <br /> OFFICE-USE:ONLY $ <br /> SERVICE-REQUEST#-- -FACILITY ID ___ -. _ <br /> AW0014T REC@IV@D CHECK# <br /> RECEIVED BY DATE RECEIVED <br /> 63Z�REVISED 08/111 by KP) <br /> -- --- <br />