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From; 0 12/008 16:42 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3024 <br />Telephone: (209) 468-3420 For. (209) 468-3433 Web: www. s' ov_or ehd <br />#216 P-003/007 <br />FACILITY NAME <br />FACIIL,IITY� CONTACT NAME <br />CLOSURE FEE = $315 / TANK <br /># TANKS X $315 = <br />FACILITY ADDRESS <br />SITE PHOAt # WITH AREA CODE <br />3j U C -k -k. ' V <br />3 4 ZIP ` A WD <br />CITY STATE <br />ZIP CODE # OF TANKS AT SITE <br />aLC.k:�--iDV1 CA <br />q5z 1 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />CLOSURE FEE = $315 / TANK <br /># TANKS X $315 = <br />APPLICANT MAILING ADDRESS <br />APPLICAN HONE # MATH AREA CODE <br />TE MPORARY CLOSURE FEE _ $3951 FACILITY <br />/J— <br />CITY STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />i t l <br />Closure Installation epai Retrofit %57 Lei 4 -LA l <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$550 FEE INCLUDES FACILITYFEE i 1 TANK (2008) <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON <br />2044 1 2005 1 2006 1 2007 1 2008 <br />PROGRAM <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # s : <br />CLOSURE FEE = $315 / TANK <br /># TANKS X $315 = <br />TEMPORARY CLOSURE <br />Plan Review and inspections) <br />TANK ID # (s) : <br />TE MPORARY CLOSURE FEE _ $3951 FACILITY <br />INSTALLATION PLAN CHECK <br />TANK ID # (s) : PLAN CHECK FEE = $840 / FACILITY <br />REPAIR PLAN CHECK <br />TANK 10 # (s) : 5 tL-p-T <br />$ <br />TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />3/,S— <br />spill buckets, sumps, mist.) <br />/J— <br />PIPING <br />PIPING REPAIR FEE = $315 / FACILITY use for piping. under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE = $ 20 <br />$ <br />CONSULTATION FEE _ $ 1051 HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 1051 HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 105/ HOUR <br />Al i FFPC Aoo e.Q— -.i ------ ---- - - ... -- - - <br />$ <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK #RECEIYE6 SY HATE RECEIVED <br />SR <br />EH 23 032 {REVISED 711 8/08i <br />