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SAN JOAQUIN COUNTY 00 fNVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orgjehd FACILITY NAME FACILITY CONTACT NAME rt' its ,I 22� FACILITY ADVRESS SITE PHONE#WITH AREA CODE 1-a) ( ( .2ol) 5-9 9 L-t I (-I I CITY I STATE ZIP CODE #OF TANKS AT SITE LMLA L] CA 9 s 3 APPLICANTBILLINGNAME APPLICANT CONTACT NAME �Gc APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE �Ab C�i-)LLt" Ao-e- (40�) CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <�) of"L --A 0&C C 9 Closure Installationg[e:p Dir Retrofit ACTIVE FACILITY $500 FEE INCLUDES FACILITY FEE+I TANK(2002-2007) 2003 2004 2005 2006 2007 1 2008 $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED $ TANK SURCHARGE=$15/TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ PERMANENT—CLOSURE (Removal or Permitted Closure in Place) TANK ID#(s): CLOSURE FEE=$294 LTANK #TANKS X$994= $ TEMPORARY CLOSURE (Plan Review and Inspections) TANK ID#(s): TEMPORARY CLOSURE FEE $294 FACILITY $ INSTALLATION PLAN CHECK (Plan Check and Construction Inspections) TANK ID#(s): PLAN CHECK FEE $784 FACILITY REPAIR PLAN CHECK TANK ID#(s): TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ spill buckets,sumps,misc.) PIPING REPAIR FEE $294/FACILITY use for piping,under-dispenser containment,ect.) MISCELLANEOUS TRANSFER FEE $20 $ CONSULTATION FEE = $981 HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR $ SAMPLING INSPECTION FEE = $98/HOUR $ ALLFEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. --------- I...... ...... OFFICE USE ONLY SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED_ SIR I I I EH 23 032(REVISED 12131107)