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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL.HEALTH DEPARTME.N'T <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov_org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> F-1 <<n -5 ,S '00-7 S <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1;a Iv J�c.l�-�cr� fZsA .i-o a -�,(s L9—. c= <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA q!5 Co <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> c rL-- <br /> APPLICANT MAILING ADDRPSS APPLICANT PHONE#WITH AREA CODE <br /> `t (o T--l Z`l-6 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> q w b Closure Installation epa Retrofit 7 L/sl('_0 <br /> ACTIVE FACILITY <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 811/07) <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=$24.00/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): I 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,mist. <br /> PIPING REPAIR FEE _$294/FACILITY use for pi in ,under-dispenser containment,ect.) $:;2 <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 0813/07) <br />