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From 11/03/2008 15 33P012/033 <br /> RECC-1VED <br /> SAN JOAQUIN COUNTY r k <br /> ENVIRONMENTAL HEALTH DEPARTMI.11 NOV 4. 2008 <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> T'etepkone:(209)468-3420 Fax:(209)468-3433 Web:MMK-Sieoyor /g a 9A-N,10ACUIN co UN17-Y <br /> ENVIRONi4 ENTAI, <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILTfY ADDRES p SITE PHONE#WITH EA CODE <br /> 5. ESC4�vh ���e 12oar -7 <br /> t:liY STATE ZIP CODE #OF TANKS AT SITE <br /> Ft.y-vV%=LA CA 2161L 2 (Al co <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> c � <br /> >ct V\ e ti I ves cs (. L~L G �.ts v\ Ste bt U.1 V►� t <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE;f WITH AREA CODE <br /> CITY STATE , ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> It-.,� , r� �7 Closure Installation Repair Retrofit s� Q fQ7 I! v <br /> ACTIVE FACILITY <br /> 2006 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) 2003 2004 2005 2 007 2008 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) <br /> $125 PER TANK AFTER FIRST TANK L � $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15 t TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24. Ol FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$315!TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Pian Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$315/FACILITY $ V <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) r <br /> $ V <br /> TANK ID#(s): PLAN CHECK FEE_$8401 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE _$3151 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> ill buckets,sumps.mist. <br /> PIPING REPAIR FEE _$315 l FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = $20 $ <br /> CONSULTATION FEE _ $1051 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $106 t HOUR $ <br /> SAMPLING INSPECTION FEE = $1051 HOUR $ <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID A_QUEST RECEIVED I CHECK# RECEIVED BY I DATE RECEIVED <br />