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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN"1 <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sj ov or /g ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> vS,A l`�e�lro (41� <br /> kstAla FACILITY ADDRESS a <br /> SITE PHONE#WITIVAREA CODE <br /> 30 - 3« <br /> CITY STATE ZIP CODE <br /> #OF TANKS AT SITE <br /> L CA Q Q- <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> crv�(�v 5+6JL0*'l S e du-S IAC, ( <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> &&CA- Aux- <br /> (4 -)-[-:�-(Q�38 <br /> CITY ( STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> CA lf-,�- Closure Installation ai Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2003-2008) 2004 2005 2006 2007 2008 2009 <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2009) <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 /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$315/TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$315/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$840/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ /c� <br /> s ill buckets,sum s,misc. 0 <br /> PIPING REPAIR FEE =$315/FACILITY use for piping, under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $ 105/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $ 105/HOUR $ <br /> SAMPLING INSPECTION FEE = $ 105/HOUR $ <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST I FACILITY ID 1 AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02/23109) <br />