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SAN JOAQUIN <br /> ENVIRONMENTAL TH DEPARTMENT <br /> 600 East Main Suvet,Stockton,CA 95202-3029 <br /> Te hone:(209)468-3420 Fax:(209)468-3433 Web:www.sPzov.orglehd <br /> FACILITY NAME FACILITY CONTACT NME <br /> FACILITY AEWRESS SITE PHONE 9 WITH AREA CODE <br /> 2-5 K) I aaw &am!E 7 <br /> CITY STATE ZIP CODE I *OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT RME <br /> G <br /> APPLICANT LI LICANT PHONE#WITH AREA CODE <br /> L` <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTORICC# <br /> Cwe Insta eftm <br /> AC <br /> FA—CILITY <br /> 2005 2006 2007 2008 2009 2010 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2005-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2010) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$49. FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in <br /> $ <br /> TANK ID#(s): CLOSURE FEE= I TANK #TANKS X 366_ <br /> TEMPORARYCLOSURE <br /> Plan Review and <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$3661 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and n inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE= 76/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE _ /FACILITY (use for monitoring equipment cold starts,EVR upgrades, <br /> U[ buckets,sumps,misc. <br /> $ <br /> PIPING REPAIR FEE _ /FACILITY LuiLe forunder-dispenser containment, <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $25 <br /> $ <br /> CONSULTATION FEE _ $1221 HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $122!HOUR <br /> $ <br /> SAMPLING 1 <br /> 'ECT FEE _ $122/HOUR <br /> ALL FEES ARE 13ASED ON THE$122 HOtIRLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE NUED M APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# LITY ID RE CHECK RECEIVED BY DATE RECEIVED <br /> SR I i <br /> EH 23 032(REVISED 07121110) <br />