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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, w�w.sjgoy,or ehd _ . _.. ..'.... _ PACILITY, NAME FACILITY CONTACT NAME rC �C.�iY1n t / • Com FACILI ADDRESS I SITE PHONE .# W H AREA CODE _STATE =ZIR,CODE # OF TANKS AT SITE C1 CA APPLICANT BILLING NAME I APPLICANT CONTACT NAME �'v r � e _L"r Vs T APPLICANT MAILING- ADDRESS - - - -- -'- APPLICANT PHONE # WITH AREA CODE (9635 WiAWW 2009 CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC #' Closure Installation Repair Retrofit ACTIVE FACILITY 2005 2006 2007 2008 2009 2010 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2005-2007), $ UNAUTHORIZED RELEASE EVALUATION FEE . _ $ 122 / HOUR $ SAMPLING INSPECTION FEE _- $ 122/ HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2010) $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 P Removal or Permitted Closure In Place TANK ID # (s), CLOSURE FEE = $366 / TANK # TANKS X $366 = ITANK ID # (5): I TEMPORARY CLOSURE FEE = $3661 FACILITY ihwr� w tr �s� TANK RETROFIT REPAIR FEE = $366 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, _.._ spill buckets sum s;.misc. PIPING REPAIR FEE = $36H'FACILITY use for piping, under -dispenser containment ect. ALL FEES ARE BASED ON THE $122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE -USE ONLY , SERVICE. REQUEST#- FACILITY ID- AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED EH 23 032 (REVISED 07121/10) TRANSFER FEE _ $ 25 $ CONSULTATION FEE _ $ 122/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE . _ $ 122 / HOUR $ SAMPLING INSPECTION FEE _- $ 122/ HOUR ALL FEES ARE BASED ON THE $122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE -USE ONLY , SERVICE. REQUEST#- FACILITY ID- AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED EH 23 032 (REVISED 07121/10)