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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orv/ehd <br /> =ESS <br /> FACILITY CONTACT NAME <br /> q <br /> Ar R k -0 L.tJ <br /> DDRSITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA 2 <br /> APPLICANT WIFEWT1211 NAME APPLICANT CONTACT NAME <br /> yra�7coE !15E <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 'P-�:) 6q- fs3-K3 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> �1 �_ Zp r Closure Installation Rep Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2003-2008) 2004 2005 2 066 2007 2008 2009 <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK( i <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$151 TANK S <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.001 FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$3151 TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> ections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$315 1 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s) PLAN CHECK FEE_ $840 1 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts, EVR upgrades, $ <br /> s ill buckets,sum s,mist. <br /> PIPING REPAIR FEE =S315 1 FACILITY use for i in ,under-dis enser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $ 105/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $ 1051 HOUR $ <br /> SAMPLING INSPECTION FEE = $ 1051 HOUR $ <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# trACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02123109) <br />