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-09/09/2009 WED 11:04 F 94683433 SJC EHD — Stockton Sesv Ell Co 2008/008 <br />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.sigov.oreehd <br />FACILITY NAMEGILITY <br />CONTACT NAME <br />APPLICANT CONTACT NAME <br />v <br />g <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />J_ <br />tv <br />2008 <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />i c' Z',•' <br />CA <br />�S I c' <br />APPLICANrNAME <br />TANK ID # s <br />APPLICANT CONTACT NAME <br />v <br />g <br />; <br />2006 <br />APPfLICANT MAILING <br />2008 <br />APPLICANT PHONE # WITH AREA CODE <br />/ADDRESS f/) <br />CITYSTATE <br />ZIP CODE <br />CIRCLE WORK -TOE DONE CONTRACTOR ICC # <br />Closure Installation (R ir' Retrofit 0 -r <br />ACTIVE FACILITY <br />TANK ID # s <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2004.2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) <br />$125 PER TANK AFTER FIRST TANK <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE =$15/TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM =$49.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # s <br />CLOSURE FEE = $345 TANKS X $345 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $345 / FACILITY <br />INSTALLATION PLAN CHECK <br />TANK ID # <br />CHECK FEE = $920 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $345 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps. misc. <br />PIPING REPAIR FEE = $345 / FACILITY use for piping, under -dispenser containment, act. <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE = $ 115/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 1151 HOUR <br />SAMPLING INSPECTION FEE _ $ 115/ HOUR <br />n 1 v-1. "' a nc a — n V ­ nM IQ. I urlC I rtA I CAV CCUJ rCCO YNIU WILL CC CILLW I U AFFUGAN r. <br />OFFICE USE ONLY <br />