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0 <br />r-� <br />LJ <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web. wwwsi9-0v.orFJehd <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />jM <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />FACILITY ADDRESS <br />/& &(;q -/g s— <br />SITE PHONE # WITH AREA CODE <br />'3 <br />'a' <br />v" <br />K -500(o <br />CITY <br />I STATE <br />I ZIP CODE 1 9 OF TANKS AT SITE <br />C , <br />CA <br />cj <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />` n tj <br />I I Merr <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />e-ly'70 �al nkee A1/1 Rd <br />/& &(;q -/g s— <br />CITY lwo cK 1 I t4 I STATE ZIP CODE <br />CIRCLE WORK TO BE DONE I CONTRACTOR ICC # <br />r—A I 9 -"7-7 <br />1 Closure Instailatlo a it etrofit 1 S2. (PZ -Z,3 <br />ACTIVE rAUU FT - <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />$ <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2007) <br />1 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br />#TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$2 <br />ill buckets, sumps, misc. <br />.3—I <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 125/ HOUR <br />$ <br />--- .. i ..w. c. nme I nni ens.eeus Fees PAW WILL BE UsiLLED To APPLICANT. <br />TOTAL AMOUNT DUE $3-15 <br />OFFICE USE ONLY <br />SIRVICK R UEST # 1 FACILITY ID LAMOUNT RECEIVED I CHECK* 1 RECEIVED BY I DATE RECEIVED <br />EH 23 032 (REVISED 0811/11 by KF) <br />