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01 <br />SAN J®F1Q�N COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />✓' 30.4 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (S'" floor): (209) 468-3433 Web: Www.si ov.or ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />c ~t C ® <br />CL4 <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />t <br />2004 <br />CITY <br />I STATE <br />ZIP CODE # OF TANKS AT SITE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />LCA <br />Lfb <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />c ~t C ® <br />1 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE #WITH AREA CODE <br />t <br />2004 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />Closure Installation a Retrofit �} - <br />ACTIVE FACILITY <br />TANK ID # (s): <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />2005 <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 /TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE= $279 /TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Review and Ins ctions .. <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE= $279 /FACILITY <br />CHECK <br />Check and <br />TANK ID # (s) : I PLAN CHECK FEE = $744 / FACILITY $ <br />REPAIR PLAN CHECK <br />MISCELLANEOUS <br />TANK ID # s <br />$ <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, s ill buckets, tank sum s, misc. <br />$ <br />PIPING REPAIR FEE = $279 / FACILITY use for 1 in ,under di ------ <br />ense <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 93/ HOUR <br />Al I FFFA ARF RASFn nW'TUC t09 I.Inl 101 v PAT= TUC TU AT Cvnc- <br />$ <br />