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0 i AY -a -W6- <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />1 <br />(k <br />D1�DRESS <br />FACILITY A2"6 <br />SITE PHONE # WITH AREA CODE <br />lJ DAM <br />trl at <br />CITY <br />ZIP CODE CIRCLE WORK TO BE DONE <br />I STATE ZIP CODE I # OF TANKS AT SITE <br />$ <br />Closure Installation a ai Retrofit <br />CA <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />E l <br />� � - <br />APPLICANT ADDRESS <br />PHONE # WITH AREA CODE <br />+M'AI`LING <br />p <br />Z V <br />fAP�P{LICANT <br />CITY STATE <br />ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />$ <br />Closure Installation a ai Retrofit <br />ACTIVE FACILITY <br />TANK ID # s : <br />CLOSURE FEE = $3901 TANK # TANKS X $390 = <br />2009 <br />2010 <br />2011 <br />2012 <br />2013 <br />2014 <br />1 $ <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK <br />$ <br />PIPING REPAIR FEE = $3901 FACILITY use for piping, under -dispenser containment, ect. <br />$130 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $151 TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.001 FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # s : <br />CLOSURE FEE = $3901 TANK # TANKS X $390 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />I TEMPORARY CLOSURE FEE = $390 f FACILITY <br />n Check and Construction Ins <br />TANK ID # <br />FEE = $10401 FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />CONSULTATION FEE = $ 1301 HOUR <br />$ <br />TANK RETROFIT REPAIR FEE = $3901 FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />jy <br />spill buckets, sumps, misc.)�j <br />1 $ <br />$ <br />PIPING REPAIR FEE = $3901 FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 1301 HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 1301 HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 1301 HOUR <br />1 $ <br />FEES ARE BASED ON THE $130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT, <br />TOTAL AMOUNT DUE I $ <br />OFFICE USE ONLY <br />SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECENED <br />EH 23 032 (REVISED 08-04.14) <br />