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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEI <br />600 East Main Street, Stockton, CA 95202-3 �, <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.or /ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />5hG11 # 13& 1 %0 Trx 5hcq 8 M ini M2irt <br />(On -site- n" 2naltf-) <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />3725 -['��� 131vd <br />?.oti 835 -71008 <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />TracA <br />f"5j:2jvw.2 <br />q537& <br />4 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />5t2rite- e- <br />Z2i'2 &2.niwo fop'. My. <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />113F 0. ne'o"11 ti -a --F-- <br />(707 76,5 -1(P(0 � Ib� <br />CITY <br />STATE <br />— <br />IP CODCIRCLE <br />WORK TO BE DONE <br />CONTRACTOR ICC # <br />f"5j:2jvw.2 <br />I ca <br />1 &14994 <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $315 / TANK <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2003-2008) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />SAMPLING INSPECTION FEE _ $ 105/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (20179) <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 CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $315 / TANK <br /># TANKS X $315 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $315 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TRANSFER FEE _ $ 20 <br />TANK ID # (s) : <br />PLAN CHECK FEE = $840 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, misc. <br />PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) $ 3 �• <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 105/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />SAMPLING INSPECTION FEE _ $ 105/ HOUR <br />ALL FEES ARE BASED ON THE $105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED DATE RECEIVED <br />SR <br />Fu -vQ wz-2 /DF\/mr-n f17/7Rinm <br />