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REGEIVED <br /> SAN JOAQUIN COUNTY MAR O 4 2016 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Ae., Stock(on,CA 95205-6232 <br /> Telephone:(209)468-3420 F xv(209)468-3433 JYeGwv+nv s' � <br /> ov.clr alta ENVIRONMENTAL <br /> FACILITY NAM I.,IIMAITU 11t::pAPT4nMNIT <br /> -'MU ILJ I T CONTACT NAME <br /> w <br /> FACILITY ADDRESS <br /> SITE PHONE#WITH AREA :00E <br /> CITY '5 " <br /> STATE ZIP ebDE <br /> CA #OF TANKS AT SITE <br /> APPLICANT BILLING NAME <br /> APALICANT CONTACT NAME <br /> APP L ANT MAIL- G ADDRES APPLICANT FI1gNE#WI H REA CODE <br /> CITY STAT ZIP CODE ` <br /> CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Re air .Retrofil <br /> ACTIVE FACELITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007-2008) 2006 2008 2010 �� 2E31.2 2013 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009.2012) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PE LTY ASSESSED <br /> TANK SURCHARGE_$151 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=335.001 FACILITY <br /> PERMANENT CLOSURE <br /> Remavaf or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE=$3751 TANK <br /> TEMPORARY CLOSURE #TANKS X$375 <br /> Plan Review and fns actions <br /> TANK ID#(s): TEMPORARY CI OSUFiE FEE=$3751 FACILITY <br /> INSTALLATION PLAN GHECK <br /> plan Check and Construction Ins actions <br /> TANK I D#(s): — — <br /> PLAN CHEGIC F1 E_$90001 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s).. <br /> TANK RETROFIT REPAIR FEE =$=5 FACILITY (use for monitoring equipment,colts starts,EVR upgrades, $ <br /> s i1I bucfceIsL. sum s,misc, E <br /> PIPING REPAIR FIE =$375/FACILITY use!Or pi in ,under-dis enser containment,ect. $ <br /> rSAMPLtNC' <br /> CELLANEOUS <br /> NSFER FEE _ $25 <br /> SULTATION FEE $ <br /> = $1257 HOUR <br /> UTIIORIZED RELEASE EVALUATION FEE _ $125111C)UR <br /> INSPECTIQN FEE _ $125!HOUR '� -- <br /> ALL FEES ARE BASED ON 711-3$125 HOURLY RATE. TIME TNAT EXCEEDS FEES PAID WILL DI=BILLED To APPLICANT: $ <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY $ <br /> SERVICE RECdUEST# FACILITY Ib AMOUNT RECEIVED GHECI(# <br /> RECEIVED DY DATERECf IVI D <br /> EH 23 032(REVfSt D 111612913 by ISE) <br />