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SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTAENnw <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(5'Jloor):(209)468-3433 Web:www.sigoy.org-/ehd <br /> FACILITY NAME �^ FACILITY CONTACT NAME <br /> #�fc � S <br /> FACILITY ADDRESS SITE PHONE MITH AREA CODE <br /> L -alS3`-1 <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> CA at52 - a <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> IIF 0 - '('SOX. (-orl) cil - g 1C0 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> yro(-) C�\ Q Closure Installation a it Retrofit <br /> ACTNE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 2000 2001 2002 2003 2004 2005 <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,spill buckets,tank sumps,misc.)1. <br /> $ <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,eG. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $93/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR <br /> SAMPLING INSPECTION FEE _ $93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02/22/05) <br />