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SAN JOAQUIN COUNTY <br />~' ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />F4R Q,, Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sigov.onglehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />,D S>� J /c <br />6un6L 76 <br />�a� G.`1'�urve S�nviisT'w�d <br />APPLICANT PHONE #WITH AREA CODE <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />e/ /0 91VC1 <br />101 c1Y3 -208'Z <br />('716) Z6?._ <br />CITY STATE <br />ZIP CODE <br />I # OF TANKS AT SITE <br />CA <br />g5 -2-o `f <br />14- &7- 9I -bet-- <br />APPLICANT BILLING NAME <br />ACTIVE <br />APPLICANT CONTACT NAME <br />,D S>� J /c <br />I -Nei t l--f70,s4x <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE #WITH AREA CODE <br />2006 <br />9A, 7 — 39� <br />CITY <br />STATE <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />Lo, <br />1C4---F'75--4-q <br />$ <br />Closure Installation Repai Retrofit <br />'Z <br />j Z 3Y 7 72- <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE= $31 WANK <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105/HOUR <br />$ <br />SAMPLING INSPECTION FEE = $105/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <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 />CLOSURE FEE= $31 WANK <br /># TANKS X $315 <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $315/FACILITY <br />INSTALLATION PLAN CHEC <br />(Plan Check and Construction <br />TANK ID # <br />PLAN CHECK FEE = $840/FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $315/FACILITY use for onitoring equipment, cold starts, EVR upgrades, <br />spill buckets sum s, misc. <br />PIPING REPAIR FEE = $315/FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />$ <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 7118/08) <br />