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Jul 07 OG 09: 48a Jeffrey C. Henley 714-739- 1499 P. 18 <br /> SAN JOAQUIN COUNTY- <br /> 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3`d Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(5"floor):(209)468-3433 Web:www-sipoy.org/ehd <br /> FACILITY CONTACT NAME <br /> FACILITY NAME <br /> -7 Co <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> OF TANKS A <br /> CITY <br /> STATE LP CODE # LSITE <br /> CA <br /> :APPLICANT <br /> ICANT BILLING NAME APPLICANT CONTACT NAMELI <br /> APPCANT PHONE#VIRTH AREA CODE <br /> MAILIN\G/ADDRESS <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC <br /> Lp C C1 ,52�acD Closure Installation pai Retrofit I SZ��p�-7 S lr+r <br /> ACTIVE FACILITY <br /> 2000 2001 2002 2003 2004 2005 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15 1 TANK - $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.001 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place) _ _ - $ <br /> # s CLOSURE FEE=$2-791 TANK #TANKS X$279 <br /> TANK va = _ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) -- $ <br /> TANK I D#(s) PLAN CHECK FEE=$744!FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$2791 FACILITY (use for monitoring equipment,spill buckets,tank sum s,misc. <br /> ed-� _ - <br /> PIPING REPAIR FEE _$279!FACILITY use forpiping,under-dispeuser containment, --_ __ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $931 HOUR - - <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $931 HOUR $ <br /> SAMPLING INSPECTION FEE _ $931 HOUR <br /> ALL FEES ARE BASED ON THE S9a HOURLY RATE- TIME THAT EXCEEDS FEES PAID MILL BE SICCED TO ApPLICANT- <br /> OFFICE USE ONLY <br /> SERVICE RECUEST M FACILITY IDAMOUNT RECEIVED CHECK# RECEIY�BY DATE RECEIVED <br /> SR <br /> EH 23 032{REVISED 02122105) <br />