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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTM <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone. (209) 468-3420 Fax: (209) 468-3433 Web: www.sj og v_org/ehd <br />FACILITY NAM <br />TANK ID # (s) : <br />FACILITY CONTACT NAME <br />lay <br />APPLICANT MAILI <br />j <br />FACILITY AD RESS <br />APPLI�CANT PHONE WITH AREA CODE <br />SITE PHONE # WITH AREA CODE <br />Q�r <br />o <br />/ j 3 <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />l� <br />CA 95201 <br />'�5 26-7 <br />Closure Installation Repair Retrofit <br />APPLI A T BILLIN <br />TANK ID # (s) : <br />CLOSURE FEE = $294 / TANK <br />APPLI T CONTACT NAME <br />APPLICANT MAILI <br />2004 <br />2005 <br />APPLI�CANT PHONE WITH AREA CODE <br />c35 <br />Q�r <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />/ j 3 <br />CITYSTATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />21bu/j7;Tv- <br />(-'6( <br />0;7A-&5- <br />Closure Installation Repair Retrofit <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 />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />$ <br />Installs as of 8/1/07) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <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 />PLAN <br />TANK ID # (s) : <br />PLAN CHECK FEE = $784 / FACILITY <br />REPAIR PLAN CHECK <br />V/ h <br />TANK ID # s <br />TANK RETROFIT REPAIR FEE = 4 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />PIPING REPAIR FEE = $294 / FACILITY use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 98/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />��-� • •--- • ••-- —• •--- �•• • • • v �• .. ,r.-. .�� a �.. a ems a nne GnIiGG VJ f G=J rHIV VV ILL 6C 61LLCU iv mi-I-LIUMIV I. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID I AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />