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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME1 <br /> �.. 600 East Main Street,Stockton,CA 95202-3,015 <br /> Telephone:(209)468-3420 Fax.,(209)468-3433 Web:www sieov ore/ehd -- - - <br /> FACILITY NAME FACILITY CONTACT NAME <br /> T o 0 ii <br /> FACILITY AD RESS SITE PHONE#WITH AREA CODE <br /> rn Ruin �. <br /> CITY .STATE 21P CODE I #OF TANKS AT SITE <br /> - CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Eur a Cn'mjpv,\X)V'S �nc� dam W\A\TE,. <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 25�fo- WILAW)R) 5TOC)�,Ln <br /> CITY STATE 2IF CODE CIRCLE WORK O B DONE CONTRACTOR ICC# <br /> Closure Installation air Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2006-2007) 2006 2007 2008 2009 2010 2011 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2011) <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 INA CUPA PROGRAM=$49.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$375/TANK #TANKS X$375= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <br /> TANK ID#(s): PLAN CHECK FEE_$1;000/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =W5/FACILITY (use Por monitoring equipment,;containment, <br /> rts,EVR upgratles, $ <br /> s ill buckets <br /> an., <br /> um s,mise. 3`15 <br /> PIPING REPAIR FEE_$375 11.11 use for I 1g,under-dispenser ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE =$125/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $125/HOUR - $. . . <br /> SAMPLING INSPECTION FEE _ $125/HOUR $ <br /> ALL FEES ARE BASED ON THE S72a HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY $ <br /> SERVICE REQUEST F FACILITY ID AMOUNTRECEIVED CHECK# <br /> RECEIVED BV DATE RECEIVED <br /> EH 23 032(REVISED 08/1/11 by KF) <br />