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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:MLN .sjgov.or ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FtZ e-km V4-E--k— kA(C 14 IN&-t- -t>© vu#A Ct v E 7- <br /> FACILITY <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> Zqq� E- b=izE_Im1, .T Sr- -2 Cc") 9K ( - 9 � 3 <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> S-r0 C le-T4 rE CA / S 2 O 5— 1 '2— <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Ac,T064 F,—A ( I ,L E e JP W144,V1, U)A-C,r ems( <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> Pito 13o 14 c( S"-L— <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> W r A-LT--o t Closure Installation epair Retrofit <br /> ACTIVE FACILITY <br /> 2002 2003 2004 2005 2006 2007 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2,'tDP?k : + $ <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 /> CLOSURE FEE_$294/TANK #TANKS X$294 <br /> TANK ID#(s): = <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$294/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$784/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> I <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) z r1 <br /> i <br /> $ <br /> i <br /> PIPING REPAIR FEE _$294/FACILITY (use for piping,under-dispenser containment,ect.) <br /> iMISCELLANEOUS <br /> i $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = $98/HOUR <br /> i $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $98/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $98/HOUR <br /> ALL FEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> r <br /> I <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK* I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 08/3/07) <br /> I <br /> { <br />