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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 F= (209)468-3433 Web:www.si ov.or /g ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Iti "1�Y � I <br /> FA ILITY ADD ESS SITE PHO #WITH MIA CO <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> �r <br /> CA <br /> APPLICANT BILLING NAME APPLIC CONTACT NAME <br /> APPLICANT�MAWNG ADDRESS APPLICANT PHONE#WITH ARE CODE <br /> � .: - _ 3 <br /> CITY STATE ZIP CODAb I <br /> E CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> < e C5 Closure Installation Repair Retrofit ° <br /> fACTIVE FACILITY <br /> 2005 2006 2007 2008 2009 2010.. <br /> 0 FEE INCLUDES FACILITY FEE+1 TANK(2005-2007) <br /> 0.FEE INCLUDES_FACILITY FEE+1 TANK(2008-2010) <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=$49.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK 1D#(s): CLOSURE FEE=$366/TANK F #TANKS X$366= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$366/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> PLAN C 4ECKFEE$9767 FACILITY-" - — — --- — <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> -- TANK RETROF(T.REPAIR-FEE $366/FACILITY'(use for monitoring equipment,.cold starts,EVR upgrades, $ <br /> —ill buckets,sum S,MISC.) <br /> PIPING REPAIR FEE =$366/FACILITY use for piping,under-dispenser containment,ect. $ <br /> _._MISCELLANEOUS -_ <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE _ $122/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $122/HOUR $ <br /> SAMPLING INSPECTION FEE _ $122/HOUR $ <br /> ALL FEES ARE BASED ON THE$122 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 BY DATE RECEIVED <br /> SIR <br /> EH 23 032(REVISED 07/21/10)' <br />