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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (5"' floor): (209) 468-3433 Web: www.sj oar /� ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />C <br />i`'�,0.ar ��{�U.l-Qt�t <br />FACILITY ADDR SS <br />SITE PHONE # WITH AREA CODE <br />180 V.i t t t-� 5-c- <br />a(� <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />�rcz c <br />CA <br />4 3`7(0 <br />3 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />Si'.�'iitiCQ- J{-�0�1 S Sttiul,lS �clC. <br />i`'�,0.ar ��{�U.l-Qt�t <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />0.0 Qvi;Vxvt k.e-' <br />41A a-43—(co3g <br />CITY <br />STATE . <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />JCj`tJL 5 Q , <br />`h <br />C' I'l l �_ <br />I Closure InstallationRepair ; Retrofit <br />I ( t I qa. _ b j <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $285 / TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 95 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 95/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $285 / TANK <br /># TANKS X $285 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />. <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE _ $285 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Ir <br />TANK ID # (s) : I PLAN CHECK FEE = $760 / FACILITY I $ <br />REPAIR PLAN CHECK <br />AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE = $285 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />$ <br />PIPING REPAIR FEE = $285 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$cam <br />MISCELLANEOUS <br />AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 95/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 95 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 95/ HOUR <br />ALL r CCa HRC DAaCU vl`I 1 nc ayJ r1VUKLT KAI C. I IMC I NAI tALtLL)Q rttJ VAIU WILL Ct CILLtU IU AYYLIGAN I. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID <br />AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />to co wt IKrvlatU U 11,4um l <br />