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ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202 Telepho . ( 209) 468-3420 Fax: ( 209) 468-3433 Web:sjgoy. _grg/ehd FACILITY NAME FACILITY CONTACT NAME C 1W if2.0 n.) -1* Zo 1 7 (o R#pt J�h[9cu/�% �mr►'! �g/ca7Z FACILITY ADDRESS SITE PHONE # WITH AREA CODE it o3 malt smw&-r g Zt — 01 7 CITY STATE ZIP CODE # OF TANKS AT SITE M At-Ti-&ZoI CA q 5 -3--5 .y BILLING NAME APPLICANT CONTACT NAME /APPLICANT —r—vLHi r'vc-- R#pt J�h[9cu/�% �mr►'! �g/ca7Z APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 7140 6d,> CSP 1)9--0 17 O gIIS &31 —! 30o LATa►e I CITY I STATE ZIP CODE CIRCLE WORK TO BED NE CONTRACTOR ICC # DR-bovi4 I C, A- y 5b! 0 Closure Installatio Repair etrofit S-2 RC1 Z ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $294 / TANK 2003 2004 2005 2006 2007 2008 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect.)$ UNAUTHORIZED RELEASE EVALUATION FEE = S 98 / HOUR $ SAMPLING INSPECTION FEE = $ 98/ HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (21'l,)8) $ $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 = $294 / TANK # TANKS X $294 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $294 / FACILITY INSTALLATION PLAN CHECK TANK ID # (s) : I PLAN CHECK FEE = $784 / FACILITY I $ I REPAIR PLAN CHECK TANK ID # (s) : \-.,, L u 5 — $ $ TANK RETROFIT R tP !R�F _ $294 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, spill buckets, sumps, mist. CONSULTATION FEE = $ 98/ HOUR PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect.)$ UNAUTHORIZED RELEASE EVALUATION FEE = S 98 / HOUR MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 98/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = S 98 / HOUR $ SAMPLING INSPECTION FEE = $ 98/ HOUR ALL FEES ARE BASED ON THE $98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID I AMOUNT RECEIVED CHECK # I RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 12/31/07)