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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,sjgov_,org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Q. U k IL <; -C- 0 P #- / Z 5 - <br />0 t c w A-ff t, U/ A, (, T-&-( <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />lS$O w- mxlNi SZ'` <br />%6 3�+-3- c(s-Z <br />CITY <br />I STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />'ZCPo <br />CA <br />9S -Sb b <br />3 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />W A, t -Te k a' -L C, I t'L e <br />0 t c w A-ff t, U/ A, (, T-&-( <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />P. C, 13 co z�;- <br />%6 3�+-3- c(s-Z <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />W- S A -CA -6 <br />CAr <br />9 s b a I <br />Closure Installation Repair etrofi <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $294 / TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK <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 />ALLATION <br />Check and <br />TANK ID # (s) : I PLAN CHECK FEE = $784 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, s ill buckets, tank sumps, misc.) <br />PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect.) <br />Z y <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 FEES ARE BASED ON THE $98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />nCCIL`F HQP nM! V <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED I CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 08/3/07) <br />