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SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTDgTrT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone.(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.ore/ehd <br /> FACILITY NAME \ FACILITY CONTACT NAME <br /> W`\ham <br /> CQ '-s" —Iio �'e7 y,�� <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE LP CODE #OF TANKS AT SITE <br /> CA gszyo 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY C _ STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> W - a'qG C,Ifj C:\S O \ Closure InstalEation epair etrofrt <br /> ACTIVE FACILITY <br /> 2003 2007 2008 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-200' 2004 2005 2006 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$151 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 Plate <br /> TANK ID#(s): CLOSURE FEE=$2941 TANK #TANKS X$294= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$2941 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$7841 FACILITY Is <br /> .REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> 3\s. $ <br /> TANK RETROFIT REPAIR FEE =$2W/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 3\s <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE _$2941 FACILITY $ <br /> (use for piping,under-disenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $981 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR $ <br /> SAMPLING INSPECTION FEE _ $98/HOUR - $ <br /> ALL FEES ARE BASED ON THE$98 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY - <br /> SERVICEREQUEST# FACILITY ID AMOUNTRECENED CHECK# -- RECEIVED BY I DATE RECEIVED <br /> EH 23032(REVISED 1213110T - - <br />