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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fair (209) 468-3433 Web: www.sigov.ora/ehd FACILITY NAME FACILITY CONTACT NAME it f1 C- rtes. o>r 2006 FACILITY ADDRESS SITE PHONE # WITH AREA CODE O r5r� -7 �-.. -) — 2- 7, -, J CITY I STATE ZIP CODE I # OF TANKS AT SITE CA UNAUTHORIZED RELEASE EVALUATION FEE = $ 1251 HOUR APPLICANT BILLING NAME APPLICANT CONTACT NAME CLOSURE FEE = $3751 TANK 2006 APPLICANT MAILING ADDRESS APPLICANT PHONE # WITHAREACODE O r5r� -7 �-.. -) — 2- 7, -, J CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # $500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) Closure Installation Repair ,fetro E,13Z 7 ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $3751 TANK 2006 2007 2008 2009 2010 2011 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) PIPING REPAIR FEF = $375 1 FACILITY use for piping, under -dispenser containment, ect. UNAUTHORIZED RELEASE EVALUATION FEE = $ 1251 HOUR $ SAMPLING INSPECTION FEE = $ 1251 HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED TANK SURCHARGE = $151 TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.001 FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $3751 TANK # TANKS X $375 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $375 1 FACILITY CHECK PI TANK ID # (s) PLAN CHECK FEE = $1,0001 FACILITY REPAIR PLAN CHECK TANK ID # (s) : $ TRANSFER FEE _ $ 25 TANK RETROFIT REPAIR FEE = $375 1 FACILITY (use for monitoring equipment, cold starts, EVR upgrades, s iIl buckets sumps, misc. CONSULTATION FEE = $ 1251 HOUR PIPING REPAIR FEF = $375 1 FACILITY use for piping, under -dispenser containment, ect. UNAUTHORIZED RELEASE EVALUATION FEE = $ 1251 HOUR MISCELLANEOUS $ TRANSFER FEE _ $ 25 $ CONSULTATION FEE = $ 1251 HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 1251 HOUR $ SAMPLING INSPECTION FEE = $ 1251 HOUR ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT I EXCEEDS rats PAID WILL BE BiLLCD IV ArM-1GAIM I. TOTAL AMOUNT DUE n CClf`C I ICI= Mil V SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED EH 23 032 (REVISED 0811111 by Kr)