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SAN JOAQUIN COUNTY ONVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.ore/ehd FACILITY NAME FACILITY CONTACT NAME '�LK£LS SLr6.s FACILIT ADDRESS SITE PHONE # WITH AREA COD aosari (?.oyi) 704�1- 791�49`- CITY STATE ZIP CODE # OF TANKS AT SITE ;-t/fC� CA -5-3 el / ) APPLICANT BILLING NAME APPLICANT CONTACT NAME Sj'i2£G CELS' Sla6�'Z �,v „�,�f � APPLICANT MAILING ADDRESS APPLICANT PHONE # WIT AREA CODE I'o r3© x 60 do`I S/,3 CITY STATE ZIP CODE IRCLE WORK TO BE DONE CONTRACTOR ICC # /f C- y} 3 losure Installation Repair Retrofit ACTIVE FACILITY TANK ID # (s) 2004 2005 2006 2007 2008 ZO)D $500 FEE INCLUDES FACILITY FEE + 1 TANK (20042007) $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 =$24.00/ FACILITY Is REPAIR PLAN CHECK TANK ID # (s) TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts. EVR upgrades, spill buckets, sumps, misc. PIPING REPAIR FEE = $315 / FACILITY use for Riping, under-dis enser containment, act. MISCELLANEOUS TRANSFER FEE _ $ 20 CONSULTATION FEE = $ 105/ HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 /HOUR SAMPLING INSPECTION FEE _ $ 105/ HOUR ALL FEES ARE BASED ON THE $105 HOURLY RATE. TIME THAT I EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED I CHECK # I RECEIVED BY DATE RECEIVED SR o0bl4,GF4000 2- 36G 37S- N6 IZl /a cu vv n» rocviccn nvmm�m