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SAN JOAQUIN COUN'T'Y <br /> ENVIRONMENTAL HEAUrti DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fav(209)468-3433 Web:www.sjgov.org/911d <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ch4vy-L" ;L0 1l S <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 33.55 4--(,vk v&iL LN Ll-n- Tq <br /> CITY STATE ZIP CODE #OF TANKS AT SIVE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> AP (CANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> It 10 I-LIL Le <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACT6R ICC# <br /> cpl- Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2003 2004 12005 2006 2607 2008 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) <br /> $125 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=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE $315 TANK #TANKS X$315 <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s) TEMPORARY CLOSURE FEE $315 FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE $840 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE $315 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc.) <br /> PIPING REPAIR FEE $315 FACILITY (use for piping under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE $20 <br /> CONSULTATION FEE $105/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE $105 HOUR <br /> U, <br /> SAMPLING INSPECTION FEE $105/HOUR <br /> ALL FEES ARE BASED ON THE$106 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# ILITY ID I AMOUNT RECEIVED I CHECK# RECEIVED BY DATE RE EIVED <br /> SR �f <br /> EH 23 032(REVISED 7/18/08) <br />