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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 Telephone: (209) 468-3420 Fax (5* floor): (209) 468-3433 Web: www.sigov.org/eh FACILITY NAME FACILITY CONTACT NAME b5 of t- - P O►� FACILITY ADDRESS SITE PHONE # WITH AREA CODE /v642 CITY STATE 'q1% %1 t <,l 0 ZIP CODE # OF TANKS AT SITE 2005 CA 'sI, S i CD APPLICANT BILLING NAME APPLICANT CONTACT NAME 14a, o A o S L-.) l L-. C�1%0 t 2002 APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2005 $500 FEE INCLUDES FACILITY FEE + 1 TANK SAMPLING INSPECTION FEE _ $ 93/ HOUR nccnc cote oetn wtt t RF Rtt I FO TO APPLICANT. CD CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # LAS o(gCv , Closure Installation Repa Retrofit XX q14 (0/''�1(0 ACTIVE FACILITY Removal or Permitted Closure in Place TANK ID # s 2000 2001 2002 2003 2004 2005 $500 FEE INCLUDES FACILITY FEE + 1 TANK SAMPLING INSPECTION FEE _ $ 93/ HOUR nccnc cote oetn wtt t RF Rtt I FO TO APPLICANT. TANK ID # (s) : TEMPORARY CLOSURE FEE _ $279 /FACILITY $ $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 TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoringequipment, s ill buckets, tank sumps, mist. TRANSFER FEE _ $ 20 TANK ID # s CLOSURE FEE _ $279 /TANK # TANKS X $279 = TEMPORARY CLOSURE Plan Review and Inspections) SAMPLING INSPECTION FEE _ $ 93/ HOUR nccnc cote oetn wtt t RF Rtt I FO TO APPLICANT. TANK ID # (s) : TEMPORARY CLOSURE FEE _ $279 /FACILITY ALLATION PLAN CHECK TANK ID # (s) : I PLAN CHECK FEE = $744 / FACILITY REPAIR PLAN CHECK $'�� TANK ID # s TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoringequipment, s ill buckets, tank sumps, mist. TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 93/ HOUR PIPING REPAIR FEE = $279 / FACILITY use for piping, under-dis enser containment, ect. UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR MISCELLANEOUS TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 93/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR $ SAMPLING INSPECTION FEE _ $ 93/ HOUR nccnc cote oetn wtt t RF Rtt I FO TO APPLICANT. ALL FEES ARE BASED ON THE row HOURLY R I E. I uvio i HA 1 cncv a UhFIGt UaC UIML.i SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 02/22105)