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' • SAN JOAQUIN COUNTY <br /> f ENVIRONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> KhtsGa Pr AM AjNr-a .),+tj-,} G. FElacK <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1-7-1'l oxam r ,+vjr. 264 toc.a — 4309 <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> Jul nl T E.c CA 'q F-3 3.7 1 j-- <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> S'uT`J Su 106(Z(a Iti L) ST' S ERV 1 C PA/ <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> P• a. 136x 146-7 qhs' 5-/1 - -788'7 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> S,+A/ MON C 4 S-&3losure Installation Repair Retrofit I ;-25-41C15- <br /> ACTIVE <br /> t"25.4(Cj$'ACTIVE FACILITY <br /> 2005 2006 2007 2008 2009 2010 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2005-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2010) $ <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): .11 1 CLOSURE FEE=$366/TANK #TANKS X$366 <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$366/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$976/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$366/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE _$366/FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 <br /> CONSULTATION FEE _ $122/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $122/HOUR <br /> SAMPLING INSPECTION FEE _ $122/HOUR <br /> ALL FEES ARE BASED ON THE$122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07/21/10) <br />