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• SAN JOAQUIN COUNTY 0 <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 />f -'e.0 S ySo <br />Sea rt L: ,s-ra r <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />I bl-) LJ. rf emon-1 S'treel <br />20 '-162 - 161 <br />CITY <br />I STATE <br />ZIP CODE <br />I # OF TANKS AT SITE <br />Stege K -to n <br />CA <br />�ISZO 3 <br />�n Kn � c,ln <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />&e -r le -r - 0 e,n Inc. <br />ndn erepwe- <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />b74l S:err-yr t u: -re T <br />92S- SSI. -7-5-SS- <br />SS -CITY <br />CITY <br />STATE ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />0 V b I . <br />CQ. ! a l.Sb d7 <br />Closure Installation 60 Retrofit <br />S'v57S -' 1S -- U'i <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $345 / TANK <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) <br />PIPING REPAIR FEE = $345 / FACILITY (use for piping, under -dispenser containment, ect.) <br />SAMPLING INSPECTION FEE _ $ 115/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) <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 =$49.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $345 / TANK <br /># TANKS X $345 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $345 / FACILITY <br />kLLATION PLAN CHECK <br />Check and Construction Ir <br />TANK ID # (s) : <br />PLAN CHECK FEE = $920 / FACILITY <br />REPAIR PLAN CHECK COn rlrl t.0 n 70 <br />TANKID#(s): <br />TRANSFER FEE _ $ 20 <br />$ �O <br />TANK RETROFIT REPAIR FEE = $345 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />3 66 <br />spill buckets, sumps, mist. <br />PIPING REPAIR FEE = $345 / FACILITY (use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 115/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />SAMPLING INSPECTION FEE _ $ 115/ HOUR <br />ALL FEES ARE BASED ON THE $115 HOURLY RATE. TIME THAT ExcEEoS rtts FAW WILL BE BiLLED TO Ar <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 07/01/09) <br />