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NOV-28-2012 17:32 From: 2098254549 To:4683433 Paee:5�11 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT / <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sjgov.DTulehd el <br /> FACILITY NAME([{� FACILITY CONTACT NAME <br /> ulC Gb 2P/1� L V � 1.A <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> D' °se rLud� A-K-P 3 i/t- 7 <br /> CITY STATE ODE #OF TANKS AT SITE <br /> CA 2j' 7 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILI OREO A PLICANT PHONE CODE <br /> Crit/ STATE 7JP CODE CIRCLE WORK TO BE GONE CONTRACTOR ICC# <br /> Closure Installation eir Retrofd <br /> ACTIVE fACILITY <br /> 2007 2008 2009 2010 1 2211 2012 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(20074008) <br /> $550 FEE INCLUDES PA014ITY FEE+1 TANK(20092012) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$151TANK <br /> STATESURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN AC A PROGRAM=$4$,001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Pennflted Closure in Place <br /> TANKID# s : CLOSU FEE=$375/TANK #TANKSX$375= $ <br /> TEMPORARY CLOSURE <br /> Plan Review ana Ins "ons <br /> TANK ID#(a): I MPORARY CLOSURE FEE_$3751 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins tions <br /> TANK ID#(s)! PLAN CHECK FEE_$1000/FACIUTY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROPIT REPAIR FEE _$3 !FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill budrels,sum ,mist. <br /> PIPING REPAIR FEE s$3751 Ause G <br /> MISCELLANEOUS <br /> TRANSFER FEE --/$25 $ <br /> CONSULTATION F E - 1251 HOUR $ <br /> UNAUTHORI RELEASE EV UAT10N FEE = $125/HOUR <br /> $ <br /> SAMPLING SPECTION FFA _ $1251 HOUR $ <br /> ALL FEE$ SASED ON THE$128 1&, <br /> OURLY RATE, TIME T EXCEEDS FEES PAID yRLL BE BILLED ib APPLICANT, <br /> TOTAL AMOUNT DUE Is <br /> OFFICE USE ONLY <br /> E REQUEST#REQUESTFACIUTYID I AMOUNTRECENED CHECK#17 <br /> NECFNED BY DATE RECEMED <br /> 9";D W2(RENSED WSM2 0y KF) <br />