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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: www.siQov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Cam ( C0 <br />Lu <br />FACILITY ADDRESS I <br />SITE PHONE # WITH AREA CODE <br />lq2 fi�'M Cori <br />( 1� ) � I <br />t - 22 <br />Cify <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />lW ' <br />CA <br />ZLu <br />SAMPLING INSPECTION FEE = $ 98/ HOUR <br />APPLICANT BILLING <br />AP LICANT CONTACT NAME <br />NAME <br />ffi' �t - <br />Lu <br />APPLICANT MAILING )IPRESS <br />APPLICANT PHONE # WI H AREA CODE <br />(oco <br />CITY STATE <br />11 2 <br />ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />CONSULTATION FEE = $ 98/ HOUR <br />2002 <br />�? Closure Installation Repair etrofit <br />�{��/ (A l <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $294 / TANK <br /># TANKS X $294 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />CONSULTATION FEE = $ 98/ HOUR <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />SAMPLING INSPECTION FEE = $ 98/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & Nevv <br />$ <br />si lls %„ :t( 8 1 i0 <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): <br />CLOSURE FEE = $294 / TANK <br /># TANKS X $294 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />INSTALLATION PLAN CHEC <br />(Plan Check and Construction <br />TANK ID # (s) : <br />PLAN CHECK FEE = $784 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # s <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />TRANSFER FEE _ $ 20 <br />PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE = $ 98/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />SAMPLING INSPECTION FEE = $ 98/ HOUR <br />ALL I•ttJAKt tIAStUUN IKt;0W*KUUKLT MAI r. umr- IMAI MA—Q— rcc.a r.,... ..�cc .+.. ...���.. .. <br />ncclrc I Ice nut v <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 0813107) <br />