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Nov 06 14 04:14p <br />Eli IV Contactors <br />12094 fo6342 p. 2 <br />i -1 P r. . i-- , i i i-- n <br />SAN JOALQUIN COUNW <br />ENviRommENrALHF-ALTx DEPARTms,I i, <br />1868 E. Ha7elton Ave., Stockton, CA 95205-E.2: N Q V 09 U14 <br />Telephone: (209) 468-3420 Fox: (209) 468-3433 Web: a.w ±.s-cehd.0 <br />Y+, NAME <br />FACILfi fTi <br />APPLICANT CONTII <br />FACILfTY CONTACT <br />f <br />I i# l+ f1 <br />` <br />APPLICANT PMONI <br />FACILITY AD RE <br />ztk1-i <br />SITE PHONE # Wi' - <br />��t <br />1 c <br />Closure instal <br />CITY <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PRG <br />ZIP CODE <br />.:� <br />CA <br />, <br />APPLICANT BILLING NAME <br />APPLICANT CONTII <br />2009 <br />2010 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PMONI <br />c ,' i MVI <br />ztk1-i <br />CITY STATE ZIP CODE <br />CIRCLE WORK' <br />1 c <br />Closure instal <br />C NAME <br />Ll c <br />.1 ilfli'H AREACODE <br />R <br />on l <br />ACTIVE FACILITY -- <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK <br />$130 PER TANK AFTER FIRST TANK <br />2009 <br />2010 <br />2011 <br />T'EWORARY CLOSURE FEE _ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $151 TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PRG <br />PERMANENT CLOSURE-- <br />Removal or Permuted Clasure in Piace <br />TANK !1] # s <br />CLOSURE FEE _ $3901 TANK <br />TEMPORARY CLOSURE <br />lan Review and lns nr s <br />TANK IIT # (s) : <br />T'EWORARY CLOSURE FEE _ <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Ir <br />TANK ID # (s) : <br />13E DOME 1 CONTRACTOR ICC # I <br />PIAN CHECK FEE 10401 FACILITY <br />REPAIR PLAN CHECK <br />TANK fD#(s): <br />TANK RETROFIT REPAIR FEE = $390 1 FACILCTY (use for rnoritaring equipment, cold :< <br />spill buckets sum misc. <br />PIPING REPAIR FEE = $3901 FACILITY use for i , under-dis ensercarlt: <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />CONSULTATION FEE _ $ '1301 HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 1301 HOUR <br />SAMPLING INSPECTION FEE = $ 130/ HOUR _ <br />FEES ARE BASED ON THE $130 HOURLY RATE. TWE.THAT EXCEEDS FEES PATO WLL BE BILl.1=C 10 A1,l�PPL.ICANT. <br />TOTAL AMOUNT DUE - $ <br />RECEIVED BY DATE RECEIVED <br />to s, EVR upgrades, <br />in lent ecL $ _} <br />2012 <br />2013 ' <br />2014IT <br />AM =$35.001 FACILY <br />PIAN CHECK FEE 10401 FACILITY <br />REPAIR PLAN CHECK <br />TANK fD#(s): <br />TANK RETROFIT REPAIR FEE = $390 1 FACILCTY (use for rnoritaring equipment, cold :< <br />spill buckets sum misc. <br />PIPING REPAIR FEE = $3901 FACILITY use for i , under-dis ensercarlt: <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />CONSULTATION FEE _ $ '1301 HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 1301 HOUR <br />SAMPLING INSPECTION FEE = $ 130/ HOUR _ <br />FEES ARE BASED ON THE $130 HOURLY RATE. TWE.THAT EXCEEDS FEES PATO WLL BE BILl.1=C 10 A1,l�PPL.ICANT. <br />TOTAL AMOUNT DUE - $ <br />RECEIVED BY DATE RECEIVED <br />to s, EVR upgrades, <br />in lent ecL $ _} <br />