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TI • • <br /> v <br /> SAN JOAQUUY COUNTY <br /> t ENVIRONMENTAL HL ALTHDEp"JMENT <br /> i 600 East Main Street,Stockton,CA 95202-3029 <br /> v Telephone:(209)468-3420 Aar (209)468-3433 Web;www s eov o /ehd <br /> ! ) FACILITY NAME <br /> FACILITY CONTACT NAME <br /> FACILITY ADDRESS Ur <br /> : SITE PHONE#WITH AREA CODE <br /> CITY <br /> STATE CODE # <br /> CA OF TANKS AT SITE <br /> �-1 <br /> APPLICANT BILLING NAME L <br /> �//_ APPLICANIT CmONTACT NAME <br /> APPLICANT MAILING ADDzrm <br /> 20 0 APPLICANTPHOI(NE#WITHAREACODE <br /> CITY STATE ZIP CODE - <br /> CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> . Cbsure InsfallaDon Re it RetroRt <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+.1 TANK(2000-2007) 2006 2007 2008 2009 2010 2011 <br /> $550 FEE INCLUDES FACILITY FEE <br /> +I TANK(2000-2011) <br /> $125 PERTANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTYASSESSED $ <br /> TANK SURCHARGE=$15/TANK <br /> $ <br /> STATE SURCHARGE FOR FACII 0IES NOT ALRF:AD(ON INVENTORYIdACUPAPROGRAM=84g.00/FACILffY $ <br /> PERMANENTCLOSURE - � <br /> Removal or permitted Closure In Place <br /> TANKID# s = <br /> CLOSURE FEE- $. <br /> TEMPORARYCLOSURE $375/TANK #TANKS X$375= <br /> Plan Review and Ins coons <br /> TANK ID#(s): <br /> TEMPORARY CLOSURE FEE=$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Consbacson Ins edons <br /> _ <br /> TANK ID#(s): <br /> ".PLAN CHECK FEE=_$1,000LFACILLrY $ <br /> REPAIR PLAN CHECK . <br /> 3FANKRETROFIT RII> - --_ .-,.._ <br /> "9�t "FSE $37b-FFA�]Ll7Y (usfodn <br /> g`EwrtkeNs au <br /> sla,EVR l ob -- -. <br /> '. PIPING REPAIR FEE=$375/FACILITY $ <br /> use for ,under-di ser containment ect <br /> TRANSFER FEE -_ $25 <br /> CONSULTATION FiEff $y25/HOUR <br /> .._.___ UNAUTHORIZEURELEASE EVALUATION�FEE . . <br /> /HOUR <br /> _.. SAMPLING INSPECTION FEE _ $WHOUR <br /> ACL FEES qRE BASE ON THE$125 HOURLY RATE.TIME THAT EXCEEDS FEES PAp)YYILL BE BILLED IYl pppDCANT. $ <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY $ I <br /> -SERVICE REQUEST# 'FACILDYIOI <br /> AMOUNT RECEIVED CHECK# RECEIVED BY DATE------ D <br /> ' EH23032(REVISED 0811111 by Kr) f 1 <br /> i <br />