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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 Far. (209) 468-3433 Web: www.s,igov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />5 II I ► 7 n I.iIn �Gq <br />e2ij2 & 2riff10 , �b r• <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />2-67`5 rangy L..inc <br />707 71x5-1 <br />CITY <br />STATE <br />I ZIP CODE <br /># OF TANKS AT SITE <br />Tracy <br />ICA <br />I 1557(P <br />14 - <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />Stan- <br />e2ij2 & 2riff10 , �b r• <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />1i37. W. me'cbuxll 51Vd• <br />707 71x5-1 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />f7ct2 4v yea <br />CA 19"154 <br />Tclosure Installation Repair ED <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $294 / TANK <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <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 (2008) <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 />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TRANSFER FEE _ $ 20 <br />I <br />TANK ID # (s) : <br />PLAN CHECK FEE = $784 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, misc. <br />PIPING REPAIR FEE = $294 / FACILITY use for piping, under -dispenser containment, ect. <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 />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 12/31/07) <br />