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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (P floor): (209) 468-3433 Web: www.siVov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />�ew�ce �Fa�cc�1 <br />.1.�..1� • I`� 1���-uu�.r�t <br />FACILITY ADDREOS <br />SITE PHONE # WITH AREA CODE <br />t'3(54 W C � - 5 '� <br />-69 1:t e <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />--�e <br />CA <br />953�� <br />3 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />�ew�ce �Fa�cc�1 <br />.1.�..1� • I`� 1���-uu�.r�t <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />(c5c 0 GZ�i w� Au -e, <br />343-1a�3 <br />CITY <br />STATE . <br />ILP. CODE CIRCLE WORKTO.BE DONE <br />CONTRACTOR ICC # <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 95 /HOUR <br />Closure Installation Repair ilRetrofit <br />$ 3 l S 3 •• fir <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 />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />$ <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 />TANK ID # (s)': <br />TEMPORARY CLOSURE FEE _ $285 / FACILITY <br />INSTALLATION <br />(Plan Check and <br />I TANK ID # (s) : PLAN CHECK FEE _ $760 / FACILITY $ <br />REPAIR PLAN CHECK <br />FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE = $285 / FACILITY use for monitoring equipment, s ill buckets, tank sumps, misc.) <br />PIPING REPAIR FEE = $285 / FACILITY use for piping, under -dispenser containment, ect. <br />$ <br />MISCELLANEOUS <br />FACILITY ID 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 />r.r.....r.s r�.�� �r�.•�v v.� 1 •.� ya "WV 1 R J C. I IIYIC 1 n1 I CA4CCUo Ecco rAI V WILL CIC t31LLtU I U AV YLII.AN 1. <br />OFFICE USE ONLY <br />SERVICE REQUEST # <br />FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />