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SAN JOAQUIN COUNTY k2-` <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA.95202-3029 <br /> • Telephone:(209)468-3420 Fru:(209)468-3433 Web:www.si7ov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> .1 dcolta � z c_ z � <br /> l L <br /> FACILITY`AD ESS SITE PHONE#WITH AREA CODE <br /> k U -?_eq +. — <br /> CITY STATE ZIP CODES #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> j2_f")Y_J W U tr - <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE ONE CONTRACTOR ICC# <br /> 'U � Closure Installation R air Retrofit <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2003-2008) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$24.001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> CL <br /> TANK ID#(s): OSURE FEE_$315!TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$3951 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$8401 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s); <br /> TANK RETROFIT REPAIR FEE _$3151 FACILITY (use for mQni'toeing equipment,cold starts,EVR upgrades, $ r <br /> 90.buckets,s m s,misc. <br /> PIPING REPAIR FEE _$315 1 FACILITY (use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $1051 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $1051 HOUR $ <br /> SAMPLING INSPECTION FEE _ $105!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 REOIiEST# FACILITY ID AMOUNT RECEIVED CHECK# JRECEIVEDBY DATE RECEIVED <br /> SFS <br /> EH 23 032(REVISED 02/23108) <br />