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F <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT - <br /> 600 East Main Street;Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fi=(209)468-3433 Web.www.sigoy.org/ehd <br /> FACIU AME FACILITY CONTACT NAME <br /> FACILITY ADD SS SITE PHONE 9 WITH AREA CODE <br /> Cl + SATE ZIP CODE /a a #OF TANKS AT SITE <br /> CA 952/U <br /> APPLICANT BILLING NAME APPU T CONTACT.NAME <br /> APP CANT MAILING ADDRESS APPLICANT PHO # <br /> CODE. <br /> C STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> - ( Closure Instaflaticn Repair Rehnfit- + <br /> ACTIVE FACILITY - <br /> $500 FEE INCLUDES FACILITY FEE+1TANK(2005-2007) 2005 2006 2007 2008 2009 2010- <br /> $55JFEEJNCLUDESFACILOY.EEE+1-TANK(200&2010 <br /> S�5 PE12 TANK AFTER FIRST'1`ANIZ._.. ..._ _ __._ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK - $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.001 FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> °TANKID#'(s : - - - CLOSURE FEE=$366/TANK #TANKS-X$366= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections)- <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$366/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ctions <br /> . —PUARnCRECR-FEE-= 976TFAC1gT1' <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT-.REPAIR-EEE-4-$366 FACILITY (use-for monitoring-egmpment;cptd Starts,EVR'uILI <br /> 1 <br /> 1bud+ets,sum s,mist. <br /> PIPING REPAIR FEE _$366 FACILITY - - - - <br /> use for i 'n uncles-dispenser containment,ect. <br /> ES�AMPLJNG <br /> CELLANEOUSNSFER FEE _ $25 $SULTATION FEE _ $1221 HOUR $ <br /> THORIZED RELEASE EVALUATION FEE = $122/HOUR $ <br /> INSPECTION FEE _ $122/HOUR $ - <br /> ALL FEES ARE BASED ON THE$122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY - <br /> SERVICEREOUEST# FACILITY ID AMODNTRECEIVED CHECK# <br /> RECEIVED BY DATE RECEIVED i <br /> SR <br /> EH 23 032(REVISED 07/21H0)' _ i <br />