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SAN JOAQUIN COUNTY ft ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. Hazelton Ave., Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s' ov.or ehd FACILITY NAME Oi _ '� i 9,t'S/-.c/K FACILITY CONTACT NAME APPLICANT CONTACT NAME J /� L aezz I FACILITY ADDRESS D.%.v/£L APPLICANT PHONE # WITH AREA CODE SITE PHONE # WITH AREA CODE CITY S 76GIf7 KSTATE CA ZIP CODE A OF TANKS AT SITE APPLICANT BILLING NAME Oi _ '� i 9,t'S/-.c/K $500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) $550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) $125 PER TANK AFTER FIRST TANK APPLICANT CONTACT NAME %R /we APPLICANT MAILING ADDRESS aezz I S&kr D.%.v/£L APPLICANT PHONE # WITH AREA CODE 32Dl L� �,' ✓17C3&V gq-56/9 CITY STATE ZJP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # $ TANK PENALTY ASSESSED Closure Installation Re air Retrofit ACTIVE FACILITY Oi _ '� i 9,t'S/-.c/K $500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) $550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) $125 PER TANK AFTER FIRST TANK 2008 2009 2010 2011 2012 2013 $ TEMPORARY CLOSURE FEE = $375 / FACILITY $ TANK PENALTY ASSESSED $ TANK SURCHARGE =$15/TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY $ PERMANENT CLOSURE nta/AL Removal or Permitted Closure in Place Oi _ '� i 9,t'S/-.c/K TANK ID # (a): pS'1-'�7 CLOSURE FEE = $375 / TANK p # TANKS X $375 = TEMPORARY CLOSURE $ Plan Review and Inspections) $ TANK ID # (s) : $ TEMPORARY CLOSURE FEE = $375 / FACILITY NO REPAIR PLAN CHECK TANK ID # (a): $ TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $ spill buckets, sumps, misc. $ PIPING REPAIR FEE = $375 / FACILITY use for piping. under -dispenser containment, act. $ MISCELLANEOUS .... , ......,.� ,,....�.. v.. TRANSFER FEE _ $ 25 $ CONSULTATION FEE = $ 125/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE _ $ 125 / HOUR $ SAMPLING INSPECTION FEE = $ 125/ HOUR $ THE ,25 NOURLY RATE. umc i nn, A1.wtw rcta PAID WILL et WILLtU TV APPLICANT. TOTAL AMOUNT DUE $ OFFICE USE ONLY SERVICE REO UEST N 1 FACILITY ID AMOUNT RECEIVED CHECKS RECEIVED BY DATE RECEIVED 3 doll, 01>1 5 10 EH 23 033 (REVISED 1116/2013 by KF)