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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEP.I.TH DEPARTMENT T <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: mam.5 <br />jggv.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />VM I Q-A, (1n A -R. <br />$ k L A- 3-1 A K C. L' E - <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />i60f S- EL l>on-wbc ST- <br />s(o 5- 2- — <br />CITY <br />STATE <br />I ZIP CODE <br /># OF TANKS AT SITE <br />S-ro c (L T -o ?4 <br />CA <br />1 9 s z o 6 <br />Z <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />UJA L -ro-r`t- -:C . C _ <br />vo I C at -P-K-L� WA- C -ra � <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2005 <br />et((-3)-'2-17frF, X I(3 -v <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />S � <br />C A- <br />T6 It, <br />Closure Installatio epai 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 />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (D.. - Ri; ,_' <br />$ <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 Ir <br />TANK ID # <br />CHECK FEE = $784 / FACI <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE = $294 / 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 />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 98/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />ALL 1 -CCA AMC 6AJCv vl\ 1-- y ------ <br />^ <br />o---- <br />^1 e1 fl= I ICC AAII V <br />SERVICE REQUEST # I FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 0813107) <br />