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4w SAN JOAQUIN COUNTY 4w ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sj og v.or /g ehd FACILITY NAME FACILITY CONTACT NAME FACILITY ADDRESS SITE PHONE#WITH AREA CODE 1I\iL ✓� � 3�� CITY STATE ZIP CODE #OF TANKS AT SITE — CA �/ � �� 2) APPLICANT BILLING NAME APPLICANT CONTACT NAME APPLICANT MAILING ADDRESS APPLICANTPHONE#WITH AREA CODE L 7�� 7//3 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# -,I -\t_\ --L;v= )-4 S II a Closure Installationepa Retrofit 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 PERMANENTCLOSURE Removal or Permitted Closure in Place TANK ID#(s): CLOSURE FEE=$294/TANK #TANKS X$294= $ TEMPORARY CLOSURE Plan Review and Ins ections 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 _ /FACILITY (use for monitoring equipment,cold starts,EVR upgrades, spill buckets,sumps, misc.) $ PIPING REPAIR FEE =,$22154'/FACILITY (use for piping,under-dispenser containment,ecl.) MISCELLANEOUS $ TRANSFER FEE _ $20 CONSULTATION FEE _ $98/HOUR $ $ UNAUTHORIZED RELEASE EVALUATION FEE = S 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 12/31107)