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Apr 12 13 08!59a <br />Mid Valley Consulting <br />A <br />530-749-9892 P.5 <br />0 <br />DAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fie: (209) 468-3433 Web: www.sigov.orpVehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />, <br />Sf C <br />0 il 6f a <br />FACILITY ADDRESS <br />SITE PH ONE <br /># WITH AREA CODE <br />lt,(?7k ju <br />qq <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2046-2007) <br />CITY <br />STATE ZIP CODE <br /># OF TANKS AT SITE <br />c r k <br />CA G' <br />Z <br />$550 FEE INCLUDES FACILITY FEE + t TANK (2008-2011 j <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />a <br />t <br />APPLICANT MAILING ADORESS <br />APPLICANT PHONE # WITH AR A CODE <br />lCq r <br />..5` -�_ & L <br />CITY j-iSTATE <br />ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2046-2007) <br />S Y6 I Closure Irstallalion Qgjepalr Retrofit tf <br />ACTIVE FACILITY <br />TANK ID# s <br />CLOSURE FEE= $366 / TANK <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />$ <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2046-2007) <br />$550 FEE INCLUDES FACILITY FEE + t TANK (2008-2011 j <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASS EESE D <br />TANK SURCHARGE = $151 TANK <br />$ <br />STAT E SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.001 FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Clasure in Place <br />TANK ID# s <br />CLOSURE FEE= $366 / TANK <br /># TANKS X $366 = <br />TEMPORARY CLOSURE <br />Plan Review and Ins eclions <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE _ $366 f FACILITY <br />PLAN CHECK <br />Plan Check <br />TANK 1D # <br />PLAN CHECK FEE = $9761 FACILITY <br />REPAIR PLAN CHECK <br />TANK ID#W: <br />$ <br />TANK RETROFIT REPAIR FEE = 83$6 f FACILITY (use for monitoring eguipmert, cold starts, EVR upgrades. <br />etc <br />r� <br />spill buckets. sumps, misc_ <br />� <br />SAMPLING INSPECTION FEE _ $ 1221 HOUR <br />$ <br />PIPING REPAIR FEE = $366 1 FACILITY (use for piping, under-dis ensercardainment, ert. <br />MISCELLANEOUS <br />TRANSFER FEE = $ 25 <br />$ <br />CONSULTATION FEE _ $ 1221 HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 122 I HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 1221 HOUR <br />$ <br />TOTAL AMOUNT DUE $, <br />OFFICE USE ONLY <br />SERVICE REQUEST O FACILITY ID AMOUNT RECEIVED CHECKS RECEIVF_D BY FDATE RECEIVED <br />EH 23 032 IREViSED 0613171 bV KF] <br />Received Time_Apr. 12._2413_ UTAM No, 2326 <br />