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• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT HECEIVED <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sicehd.com <br /> FACILITY NAME FACILITY CONTACT NAME 2015 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> I CA 67_f;-z' /(o <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> PE fro lea kvc 44t)lee rl ehSlt-k l-') <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> yleaSa I Closure Installation a it Retrofit <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK 2009 2010 2011 2012 2013 2014 <br /> $130 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$390/TANK #TANKS X$390= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$390/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1040/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$390/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE=$390/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $130/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $130/HOUR $ <br /> SAMPLING INSPECTION FEE = $130/HOUR $ <br /> FEES ARE BASED ON THE$130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $3 qj <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 08-04-14) <br />