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00SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:NvWw.sjgov.or9/ehd FACILITY NAME FACILITY CONTACT NAME S 0-+C'.0 M LuAi i KCS–,4vLI-C-L,1 FACILITY ADDRESS SITE PHONE#WITH AREA CODE t� O A' w -1 I 8 3 0 --- -1 g'S-0 CITY STATE ZIP CODE #OF TANKS AT SITE �r 4e CA t 53-j .3 APPLICANT BILLING NAME APPLICANT CONTACT NAME Ably 0- v Lk&,u.e�-e, APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE (o 3 U &,jL'%ALA /4u-f— "D '�)-1 b -- &0 3 $ CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# Cr �-j(;I— Closure Installation Repair Retrofit Ste, $ y"(s d ACTIVE FACILITY 2003 2004 2005 2006 2007 2008 $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) $125 PER TANK AFTER FIRST TANK $ $ TANK PENALTY ASSESSED TANK SURCHARGE=$15/TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID#(s): CLOSURE FEE=$294/TANK #TANKS X$294= TEMPORARY CLOSURE Plan Review and Inspections) $ TANK ID#(s): TEMPORARY CLOSURE FEE_$294/FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID#(s): PLAN CHECK FEE_$784/FACILITY REPAIR PLAN CHECK TANK ID#(s): $ TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, spill buckets,sumps,misc.) $ PIPING REPAIR FEE _$294/FACILITY (use for piping,under-dispenser containment,ect. MISCELLANEOUS $ TRANSFER FEE _ $20 CONSULTATION FEE _ $98/HOUR UNAUTHORIZED RELEASE EVALUATION FEE _ $98/HOUR SAMPLING INSPECTION FEE _ $98/HOUR ALL FEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED SR EH 23 032(REVISED 12131107)