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0 - SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> • <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(5°floor):(209)468-3433 Web:www.siaov.orl>/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> n o ccs s -" -2 ? v5H ce <br /> S- <br /> FACILITYADDRESS SITE PHONE#WITH AREA CODE <br /> /lob Acev-clL_ Lao. -Q zl)rr 97�3 —toy g17 <br /> CITY STATE ZIP CODE F#—OF TANKS AT SITE <br /> 54vc*- -1 y CA 952-(4 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Cis T�tl� �- <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 697-1 CF. Lacjd(riv J q .310 S-- /Z L[ 6� <br /> CITY STATE 'LIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> t; j�L rcM C/,q C( S'ZULO Closure Installation 00r etrofit <br /> ACTIVE 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 1 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#(a): CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): 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#(a): <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY use for monitoring equipment,s ill buckets,tank sumps,misc. <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,ect. $�7 <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# I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02122105) <br />