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• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEO CEIVE® <br /> Y <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www sjcehd com MAR 16 2015 <br /> FACILITYNAME - FACILITY CONTACT NAME <br /> Cc)� ccl <br /> ENVIROWNTAL <br /> FACILITY.ADDRESS . SI E. ONE#WITH AREA CODE AAFNT <br /> :oto C -homme,-cmc) . 209 h95 -qt 166 <br /> 'CITY' STATE ZIP CODE I #OF TANKS.AT SITE <br /> 5 _ct . CA `352 <br /> APPLICANT BILLING NAME APPLICANT.CONTACT NAME <br /> �LIl�T�1 C%�lTKE1CTUP j ( <br /> APPLICANT MAILING ADDRESS. APPLICANT PH NE#WITH AREA CODE <br /> - 2535 �i�itx)P[�l pp.o <br /> CIN 5 STATE ZIP CODE CIRCLE WONK T BE DONE CONTRACTOR ICC# <br /> Closure Installation R air Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007-2008) 2007 2008 2009 2010 2011 2012 , <br /> $550 FEE INCLUDES FACILITY FEE+.1 TANK(2009-2012) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> -TANK PENALTY ASSESSED $ <br /> _..........._.._.—_TANUUROHARGE.=_$1 !_TANK.._. <br /> STATE.SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$49.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permttted Closure In Place <br /> .TANKIR# s:. CLOSURE FEE=.$375/TANK #TANKS X 375.= $ <br /> TEMPORARY CLOSURE - - <br /> . . ......_ElaliBeviewandans actions <br /> TANK.IO.#(s): TEMPORARY CLOSURE FEE_$3751 FACILITY <br /> i <br /> .INSTALLATION PLAN.CHECK <br /> Plan CheY and Construcdon Ins ectlons <br /> TANK-113-9(s): PLAN CHECK FEE=$10001 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$3761FACIOTY'(use for monitoring equipment mIcl stalls;EVR upgrades, $ <br /> vt <br /> s lll-buakets-sumpsi miss,)."... ..... _ .. . <br /> PIPINGREPAIRFEE =$375/FACILITY use for piping,under-dispenser containment act. <br /> MISCELLANEOUS <br /> .TRANSFER:FEE .. =.$.25 ._.._ $ <br /> CONSULTATION FEE $1251 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = 1251 HOUR - - $ <br /> SAMPLINGTNSPECTION:FEE- 1251 HOUR, $ <br /> "'ALL FEES"AREBASED ON THE LY'RATE"TIME-THAT EXCEEDSFEES'PAID WILL BE BILLED TO-APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> -OFFICE`DSE'ONeY__ -. <br /> EH 23 032(REVISED 04113112 by KF) <br />