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• SAN JOAQUIN COUNTY h <br /> ENVIRONMENTAL HEALTH DEPARTMH <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(9''floor):(209)468-3433 Web:www.sigov.org/eb <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ((Ian Ccs, ► ,' or y Fo o ej O-ef )C0.n d (nw <br /> FACIILITY ADDRESS cam. SI-TTEPPLHONE#WITH AREA CODE <br /> t <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> l(VI`KCCL CA "IstrJ )l0 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ,J-9-,e+ ay)A ti—u- - <br /> -APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> q o N . M6 n kq z3ai-�55� <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> j�/j3L Closure Instellatlan Repel Retrofit �o2yo2} q—tA <br /> ACTIVE FACILITY <br /> 2000 2001 2002 2003 2004 2005 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$279 I TANK #TANKS X$279= <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspection) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$278/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction inspections) <br /> PLAN CHECK FEE= 744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE = 279/FACILITY use for monitoring ui ment,spill buckets,tank sumps,misc.) <br /> $ <br /> PIPING REPAIR FEE _$279/FACILITY use for pipN,under—dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = $93/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE $93/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE&LLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST FACILITY ID AMOUNTRECENED CHECK# RECENED <br /> BY GATE RECENFD <br /> rSR <br /> EH 23 032(REVISED UMMS) <br />