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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Far. (209) 468-3433 Web: www.sj og v.or /,g ehd 6 FACILITY NAME FACILITY CONTACT NAME eALEOW `1n) WPM FACILITY ADDRESS SITE PHONE # WITH AREA CODE 11 H � X62-1 CITY STATE ZIP CODE # OF TANKS AT SITE �Tr ro, CA0620 2db 2— APPLICANT BILLING NAME APPLICANT CONTACT NAME II f t1 1 1 I Li APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE t f'ti'i D . ` 0 - 6,661 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # nlahbN Closure Installation Repair Rbtofit I d k , F ACTIVE FACILITY 2003 2004 2005 2006 2007 2008 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) $550 FEE INCLUDES FACILITY FEE + 1 TANK (2005) $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED TANK SURCHARGE = $15 / TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $315 / TANK # TANKS X $315 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE= $315 / FACILITY REPAIR PLAN CHECK TANK ID # (s): TRANSFER FEE _ $ 20, TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, spill buckets, sumps, misc.)IJ 1._J PIPING REPAIR FEE = $315 / FACILITY use for piping, under -dispenser containment, ect. MISCELLANEOUS TRANSFER FEE _ $ 20, CONSULTATION FEE _ `$ 105/ HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $105 / HOUR SAMPLING INSPECTION FEE _ $ 105/ HOUR ALL FEES ARE BASED ON THE $105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 7/18/08)