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SAN JOAQUm' 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.sjog v.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Q Q)R <br />M% <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />2006 <br />(S\O (OS� - zso <br />CITY STATE <br />ZIP CODE # OF TANKS AT SITE <br />VICA-C-CA <br />s a 0 3 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) <br />$125 PER TANK AFTER FIRST TANK <br />2003 <br />APPLICANT MAILING AD SS <br />APPLICANT PHONE # WITH AREA CODE <br />2006 <br />2007 <br />CITY <br />STATE ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />$ <br />Closure Installation Repair Retrofit <br />A(: 1 IMt I-AUIU 1 T — - <br />TANK ID # s <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 />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />1 <br />PIPING REPAIR FEE = $2941 FACILITY use for piping, under -dispenser containment, eat.) <br />$ <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= $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 CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : PLAN CHECK FEE = $784 / FACILITY <br />.REPAIR PLAN CHECK <br />TANK ID#(s): <br />- 0 <br />$ <br />TANK RETROFIT REPAIR FEE-$294ACILITY use for monitoring equipment, cold starts, EVR upgrades, <br />1 <br />S it Ucke sumps, misc. <br />1 <br />PIPING REPAIR FEE = $2941 FACILITY use for piping, under -dispenser containment, eat.) <br />$ <br />TRANSFER FEE _ $ 20 $ <br />TATION FEE = $ 98/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $98/HOU R <br />SAMPLING INSPECTION FEE - $ 98/ HOUR ' <br />ALL FEES ARE BASED ON THE $98 HOURLY RATE. TIME THAT EXCEEDS FEES.PAID tNILL BE BILLED TO APPLICANT. <br />OFFICE.USE ONLY <br />SLJtVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECENED BY DATE RECEIVED <br />JR...r•,r.asfr <br />EH 23 032 MI MISED 12nitmin <br />