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SAN JOAQUIN COUN'T'Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax. (209)468-3433 Web:www.s,jov.orwehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 13 P1 f 4� ., <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> .- <br /> CITY STATE ZIP COD�-E} #OF TANKS AT SITE <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT AILING ADDRESS I APPLICANT PHONE#WITH AREA CODE <br /> a <br /> C"herc+tc3 XC Irg <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> CA I q5' <br /> Closure Installation Repa' Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2003-2008) 2004 2005 2006 2007 2008 2009 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24,001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$3151 TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$3151 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Pian Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$840 1 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$315 1 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets,sumps,misc.) <br /> PIPING REPAIR FEE _$315 1 FACILITY (use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $105!HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1051 HOUR $ <br /> SAMPLING INSPECTION FEE = $1051 HOUR $ <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TUNE THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02123104) <br />