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09/18/2006 09:16. 2094683433 EHD PAGE 06 <br /> • SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARThIENT <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202-2708 <br /> Telephone.,(2 09)468-3 42 0 Fax(51'floor),(20 9)468-3433 Web.,v_roww.siQov.orP/ehJ <br /> FACILITyY�NAME FACILITY CONTACT NAME <br /> FACILITY ADD� I � <br /> I—� I� <br /> � SITE PHONE iWITH A-4 <br /> L 3bc-- (2,-703 <br /> CITY-- STATE 21P COD #OF TAN AT T ITE <br /> ICA <br /> APPLICANT BILLING NAME APPLICANT CONTACT <br /> rd g <br /> APPLICANT MAILING ADDRESS APPLICANT P NE#WITH AREA CODE <br /> n a (3 55 585- <br /> CI //T��AinnE TAP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Y r 11-1 Closure Installaton Repair Retrofit <br /> ACTIVEFACIUTY - <br /> 2004 <br /> $500 FEE IIVCLUUES FACILITY FEE+i TANK 2001 2002 2003 2005 2006 <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ ' <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENT RY IN A COPA PROGRAM=$24.00/.FACILITY $ <br /> PERMANENTCL URE - - <br /> 1Rem2val or Pefmhtad Closuroiin"Place) <br /> T ANK ID#(s). CLOSURE FEE=$2851 YANK III TANKS X$285 <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE-$285/FACILITY <br /> (Plan Check <br /> PLA CHECK <br /> Plan check antl Construcllon Inspedio� <br /> TANK 10#(s) __ PLAN CHECK FEE s$7601 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK 10#(s). <br /> TANK RETROFIT REPAIR FEE.=$255/FACILITY (use for monitoring Mulpment,spill buckets,tank 4Ump6,mist.) <br /> PIPING REPAIR FEE $2951 FACILITY (useforpiping,under,dispenser containmenteel.) $ <br /> r <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 _ $ <br /> CONSULTATION FEE $951 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE • S 951 HOUR S_� <br /> SAMPLING INSPECTION FEE _ $951 HOUR .�L.$ <br /> ALL FE 5 ARE BA9KD ON THE S%NOVRLY RATE. TIME THAT EXCEEDSE9?AID NnLL SE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIV CHECK# _ RECEIVE Y I DATE R156MV D <br /> SH <br /> EHZ9 032(REVISED 07126106) <br />