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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN'l <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.sjgov.or <br /> FACILITY NAME FACILITY CONTACT NAME <br /> I" (O 1 Tar- 1c.,4--' k <br /> ADDRESS SITE PHONE#WITH AREA CODE <br /> 0+49 )fie-4I-lemon Lane 'Do9 8('0q <br /> CITY II STATE ZIP CODE #OF TANKS AT SITE <br /> LcA CA TJ54a 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> a IPe4rJPum Fd(-n rdS <br /> APPLICANT MAILING ADDRESS V APPLICANT PRONE#WITH AREA CODE <br /> 05 c-k, C-�-, n Fled. 5�5-� )5 <br /> CITY STA n ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> �w r rk C Closure Installation Repair trofi InDy Q'ow <br /> ACTIVE FACILITY <br /> 2001 2002 2003 2004 2005 2006 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <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): CLOSURE FEE=$285/TANK #TANKS X$285= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$285/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$760/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$285/FACILITY use for monitoring equipment,s ill buckets,tank sumps,misc. $o<a5 <br /> PIPING REPAIR FEE _$285/FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $95/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $95/HOUR $ <br /> SAMPLING INSPECTION FEE = $95/HOUR $ <br /> ALL FEES ARE BASED ON THE$95 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SER <br /> SR UEVICE REQST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 07/28/06) <br />