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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd FACILITY NAME FACILITY CONTACT NAME 30-1-70 e FACILITY ADDRESS SITE PHONE # WIT AREA CODE /o Ste/ �rft r ��Gc'� C'�( %•S Z _ `� CITY STATE ZIP CODE # OF TANKS AT SITE CA CITY STATE APPLICANT BILLING NAME TANK ID # (s): APPLICANT CONTACT NAME �,� rte, 2005 2006 APPLICANT MAILING ADEIRESS 2008 APPLICANT PHONE # WITH AREA CODE MO w S,4 '3-7-31b 9 3 (Q -F z (( (,,' CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) U Closure Installation ofit ACTIVE FACILITY TANK ID # (s): CLOSURE FEE 1 $345 / TANK 2004 2005 2006 2007 2008 2009 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) $ PIPING REPAIR FEE = $345 / FACILITY use for piping, under -dispenser containment, ect.) $ SAMPLING INSPECTION FEE _ $ 115/ HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) $ $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 =$49.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE 1 $345 / TANK # TANKS X $345 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $345 / FACILITY INSTALLATION PLAN CHECK (Plan Check and Construction Ir TANK ID # PLAN CHECK FEE = $920 / FACILITY REPAIR PLAN CHECK TANK ID # (s) : $ TRANSFER FEE _ $ 20 TANK RETROFIT REPAIR FEE = $345 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, _ spill buckets, sumps, misc.)) $ PIPING REPAIR FEE = $345 / FACILITY use for piping, under -dispenser containment, ect.) MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 115/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR $ SAMPLING INSPECTION FEE _ $ 115/ HOUR 1LL FEES ARE BASED ON THE $ii5 HOURLY RATE-.- tr I IME I FIA I tAULEUS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 07/01/09)