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WSAN JOAQUIN COUNTY <br />IRONMENTAL HEALTH DEPARTMENT" <br />304ast Weber Avenue, 3" Floor, Stockton, CA 95202-2708 <br />Telephone. (209) 68-3420 Fax (5hfloor): (209) 468-3433 Web: www.sigov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />(r'erVt1i� 9//[`-1 <br />_ <br />�G rrL� it c e" -/_z <br />FACILITY ADDRESS <br />SITE PHONE :# WITH AREA CODE <br />-3'3 t j Nit l v, S 7` <br />_ <br />?U el r 2 3/-3 <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />/rC <br />CA <br />1 9J-261&) Closure Installation air Retrofit <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />CL,u (L -k -L (6 v <br />_ <br />�G rrL� it c e" -/_z <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2003 <br />L - <br />CITY <br />STATE <br />ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />/rC <br />Cl,14- <br />1 9J-261&) Closure Installation air Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />$500 FEE INCLUDES FACILITY FEE + 9 TANK <br />$125 PER TANK AFTER FIRST TANK <br />2000 <br />2001 <br />2002 <br />2003 <br />1 2004 <br />2005 <br />$ <br />SAMPLING INSPECTION FEE = $ 3/ HOUR <br />ALL FEES.e=0"M..............••...-.. _...__..---"-----------.___._ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE =$15/TANK <br />$ <br />STATE SURCHARGE FOR FACILITIESINOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />$ <br />PERMANENTCLOSURE <br />Removal or Permitted Closure in Place - <br />TANK ID # (s): <br />CLOSURE FEE = $279! TANK <br /># TANKS X $279 - <br />TEMPORARY CLOSURE <br />Plan Review and Inspections)- <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # s <br />$ <br />TANK RETROFIT REPAIR = $279 / FACILITY use for monitoring equipment, spill buckets, tank sumps, misc.)$ <br />$ <br />eFEE <br />PIPING REPAIR FEE = $2'79 / FACILITY use for piping, under-dis ensw wntainment, ect. <br />$ <br />MISCELLANEOUS <br />• <br />OF .FICEE U <br />U <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 93/ HOU <br />$ <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 3/ HOUR <br />ALL FEES.e=0"M..............••...-.. _...__..---"-----------.___._ <br />U . SE ONLY nw .. .....,�...n. , nc ♦a.a nvvn... nn,e. mc .nn. CAcCCUs rtes rw"ILL BE eILLt1U APPLICANT. <br />OF <br />