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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME <br /> 600 East Main Street,Stockton,CA 95202-3 <br /> Telephone.(209)468-3420 Fax:(209)468-3433 Web:www.siizov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY AULIKESS, I SITE PHONE WITH AREA CODE <br /> CIN I STATE ZIP CODE #OF TANKS AT SITE <br /> CA �1 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME) U, ' �dvys ' ( �'0"11 C— ff A <br /> IN <br /> APPL CANT—MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> W 1 Y <br /> CITY STATE I ZIP CODE CIRCLE WORK TO E DONE CONTRACTOR ICC# <br /> Closure installation Repair Retrofit <br /> ACTIVE FACILITY <br /> A <br /> 2002 2003 2004 2005 2006 2007 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008&New <br /> Installs-as of 8/1/07) $ <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=$24.001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$294/TANK #TANKS X$294= $ <br /> TEMPORARY-CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$294/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$784/FACILITY $ <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 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# I FACILITY ID AMOUNT RECEIVED I CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 08/3/071 <br />