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AOLi - 2Yl- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT '�' M �a 1868 E. Hazelton Ave., Stockton, CA 95205-6232 �j "i V° Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: wwwr.sicehd.corn FACILITY NAME FACILITY CONTACT NAME L T `r 1n � I�S \ _ Nm APPLICANT PHONE # WITH AREA CODE FACILITY ADDRESS SITE # WITH AREA CODE Lfi 1 t't /P�HONE (LSA I CITY STATE ZIP CODE # OF TANKS AT SITE Closure Installation R air Retrofit CA 521f. qb 2 APPLICANT BILLING NAME APPLICANT CONTACT NAME EMIEMIUM CWTMaU5 APPLICANT MAILING ADDRESS _ Nm APPLICANT PHONE # WITH AREA CODE 2010 2011 CITY STATE ZIP CODE CIRCLE WORK TO OE DONE CONTRACTOR ICC # L Closure Installation R air Retrofit FA NV I IV C I -AW LI IT TANK ID # s : $550 FEE INCLUDES FACILITY FEE ¢ 1 TANK $130 PER TANK AFTER FIRST TANK 2009 2010 2011 2012 2013 2014 TANK PENALTY ASSESSED $ TANK SURCHARGE= $15 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY $ PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # s : C LOSURE FEE= $390 /TANK #TANKS X$390 = TEMPORARY CLOSURE Plan Review and inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $390 / FACILITY Construction I TANK ID # (s) : I PLAN CHECK FEE = $1040 / FACILITY I -:4 REPAIR PLAN CHECK TANK ID TANK RETROFIT REPAIR FEE = $390 / FACILITY (ysef6—r—m--oWVdng equipment, cold sta , EVR upgrades, Sspill bucketglsumps, misc.)3�r�) $ PIPING REPAIR FEE = $390 / FACILITY use for piping, under dis enser containm ttt, eCL $ MISCELLANEOUS TRANSFER FEE _ $ 25 CONSULTATION FEE _ $ 130/ HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $ 130 /HOUR SAMPLING INSPECTION FEE = $ 130/ HOUR FEES ARE BASED ON THE $130 HOURLY RATE- TURF TNeT cYrc:c F EES PAID WILL BE BILLED TO APPLICANT. TOTAL AMOUNT DUE OFFICE USE ONLY SERVICE REQUEST # 1 FACILITY ID AMOUNT RECEIVED I CHECK # RECEIVED BY DATE RECEIVED EH 23 032 (REVISED 08-04-14)