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0 .. 4, t,, $v _ ,SUN 2 9 2016 SAN JOAQUIN COUNTY 5�. ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. Hazelton Ave., Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web, wwwsigroy.ordefid 20i6 F I ITY AME FACILITY CONTAGT NAME APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE (an) 15'r4q1 4101 d eF FACILITY ADD ESS SITE PHONE #WITH AREA CODE I ZIP CODE CIRCLE WORK 0 BE DO (( 9 41." (" s CITY STATE Z CODE # OF TANKS AT SITE CA APPLICANT ISILLING NAME APPLICANT CONTACT NAME TANK ID # s APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE (an) 15'r4q1 4101 CITY SAE I ZIP CODE CIRCLE WORK 0 BE DO CONTRACTOR ICC # 2013 Closure Installation al ACTIVE FACILITY TANK ID # s CLOSURE FEE _ $375 / TANK 2008 2009 2010 2011 2012 2013 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2047-2008) UNAUTHORIZED RELEASE EVALUATION FEE = S 1251 HOUR $ SAMPLING INSPECTION FEE _ $125! HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED TANK SURCHARGE - $151 TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$36.001 FACILITY PERMANENT CLOSURE Rarltoval of Permitted Clusure in Place - TANK ID # s CLOSURE FEE _ $375 / TANK #TANKS X $375 = TEMPORARY CLOSURE Plan Review and tns actions TANK ID # (s) : TEMPORARY CLOSURE FEE = $375 / FACILITY i REPAIR PLAN CHECK TANK ID # (5) $ TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, coli starts, EVR upgrades, ' split buckets sumps, miso. $ CONSULTATION FEE _ $ 1251 HOUR PtM MISCELLANEOUS $ TRANSFERFEE _ $ 25 $ CONSULTATION FEE _ $ 1251 HOUR UNAUTHORIZED RELEASE EVALUATION FEE = S 1251 HOUR $ SAMPLING INSPECTION FEE _ $125! HOUR ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. TOTAL AMOUNT DUE $ SERVICE REQU ST # FACILITY ID _ AMOU T RECEIVED CHECK # RECEIVED BY DATE RECEIVED EM 23 032 tKEYt5E0 171612013 Dy Ktl