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SAN JOAQUIN COUNTY *4_, <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sjeov.ore/ehd <br /> FACILITY NAME ww`` ``nn,,��,, '`l �d , FACILITY CONTACT NAME <br /> �F � ` C <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 14� t4p<e A LAOS ZcA 45L1 I W)-V5 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(20042007) <br /> $550 FEE INCLUDES FACILITY FEE +1 TANK(2008-2009) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$345/TANK #TANKS X$345= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$345/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE=$920/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$345/FACILITY (use for monitoring equipment,cold starts.EVR upgrades, <br /> spill buckets,sumps,misc. <br /> $ <br /> PIPING REPAIR FEE _$345/FACILITY (use for piping,under-dispenser containment,ect.) 2 lD0fo• <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $115/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $115/HOUR <br /> SAMPLING INSPECTION FEE _ $115/HOUR <br /> ALL FEES ARE BASED ON THE$115 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WALL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED I CHECK# RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07/01/09) <br />