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SAN JOAQUINCOUNTY <br /> E O AL ALTH DEPART <br /> 0 RECEIVED <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone. (209)468-3420 Fav(209)468-3433 Web. .s' ov.or ehd <br /> OCT 1 <br /> FACILITY RIWE FACILITY CONTACT NAME <br /> 1,. HEAH <br /> LT <br /> FACILITY ADDRESS sl PHONE# AREA CODE a=T <br /> CITY STATE ZIP CODE # TANKS T SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STA ZIP CODE CIRCLE O TO BE DONE CON CTORMICC <br /> Closure Installation R air Retrofit <br /> ACTIVE FACILITY <br /> 2008 2009 2010 2011 2012 2013 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007-2008) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009-2012) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$151 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35. FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place) <br /> CLOSURE FEE=$3751 TANK TANKS K$375= <br /> TANK ID s <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID 0(s): TEMPORARY CLOSURE FEE=$375/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construdon Ins c6ons <br /> TANK ID#(s): PLAN CHECK FEE=$1000/FACILITY <br /> REPAIR P N CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK RETROFIT REPAIR FEE =$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE _$3751 FACILITY (use for piping,under-d!s ser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $125/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1251 HOUR <br /> SAMPLING INSPECTION FEE = $125/HOUR $ <br /> ALL FEES ARE BASED ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID I AMOUNT D I ZAIR# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 111 13 by <br />