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• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTM NO IJV <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sijzov,OrL/chd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 1 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> an ( }� �i <br /> STATE ZIP CODE #OF TANKS AT SITE <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Eu�E C�i w�c� 5 e nc dam 1Om rf_�' <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 25�b Wiuwnfb�M. s[c�.Ar 1 H <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> #= Closure Installation Re air Pm—nt <br /> rFEE <br /> ILITY <br /> CLUDES FACILITY FEE+1 TANK(2006-2007) 2006 2007 2008 2009 2010 2011LUDES FACILITY FEE+1 TANK(2006-2011)NK AFTER FIRST TANK $TY ASSESSED $ARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK <br /> TID#(s): CLOSURE FEE_$375/TANK #TANKS X$375= $ <br /> EMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1,000/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(S): <br /> TANK RETROFIT REPAIR FEE -$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> -nil buckets,.sum s,miser) <br /> PIPING REPAIR FEE_$375/FACILITY use for pipn2,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $125/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $125/HOUR <br /> $ <br /> SAMPLING INSPECTION $125/HOUR $ <br /> ALL FEES ARE BASED ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY $ <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# <br /> RECEIVED BY DATE RECEIVED <br /> EH 23 032)REVISED 09/1/11 by KF) <br />