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W / ' . Nrp,lr', )'Y ' , ....v � <br /> r <br /> i <br /> 1 , ; . <br /> .. SAN JgAQUIN COUNTY ,�C(,J. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax..(2Q9)468-3433 Web:WWW.sieov.ore/ehd <br /> MN]FACILITY CONTACT NAMESITE PHONE#WITH AREA CODEZIP CODE #OF TANKS AT SITE <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME_ - <br /> ��a an'194*,mCb g nc, <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 25 5 Wi+a1>J�am M( 5Cc a--M <br /> CITY STATE_ ZIP CODE CIRCLE WORK!g B DONE — —CONTRACTOR ICC# <br /> Closure Installation air Retmtit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2066.2007) 2006 2007 2008 2009 2010 2011 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2011)$125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIENnT <br /> ALREADY ON INVENTORY INA CUPA PROGRAM m$49.00/FACILITY $ <br /> [(Removal <br /> MANENT CLOSURE <br /> or Permitted Closure in Place <br /> K ID# s : CLOSURE FEE $375/TANK #TANKS X$375PORARY CLOSUREn Review and Ins ctions <br /> TANK ID#(a): 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 /> s III buckets,sumps,mist. <br /> PIPING REPAIR FEE_$375/FACILITY use for piping,under-dispenser containment,ect <br /> MISCELLANEOUS <br /> TRANSFER FEE' = $25 $ <br /> ---CbNtULTATION FEE _ $ <br /> UNAUTHORIZEDRELEASE EVALUATION FEE = $125/HOUR $ <br /> rSAMPLING INSPECTION.FEE = $125/HOUR $ <br /> __.ALLFEES-ARE BASEDON-THE-§725HOUR6YRATETIME"rHAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY _ <br /> _- _SERVICE.REQUEST# ----=FACILITYID'"--'-'AMtlUNT RECEIVED I CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED NMI by KF) ' <br />