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Mar 28 08 10:03a Sandra Barnhart 2098458586 p.8 <br /> SAN <br /> J A UIN COUNTY to <br /> O Q <br /> ENVIROWENTAL HEALTH DEPART 4ENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web: www.sjgov.orJehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> AV—VuSSS_ � - <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> I Ic)c '5 . MC,,i i'\ -<,-�. X09 Fvs- 67 s `/l <br /> CITY STATE I ZIP CODE #OF TANKS AT SITE <br /> N'�cu/-�J-(f CA 9533 <br /> APPLICANT BILLING NAME APPLICANT CONTACT N ME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> dO <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONECONTRACTOR ICC# <br /> Cool ,j e C,- 953. Zl1 Closure Installation epair Retrofit <br /> ACTIVE FACILITY <br /> 2003 2004 2005 2006 2007 2008 <br /> 5500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2018) — "- <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$151 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=S24.001 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place _ <br /> TANK ID#(s): CLOSURE FEE=$294 I TANK #TANKS X$294= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins eclicns <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$294/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspegmns <br /> TANK ID#(s): PLAN CHECK FEE=$784/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s):a <br /> TANK RETROFIT REPAIR FEF =$2941 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc.)/ J <br /> PIPING REPAIR FEE _$254/FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $981 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $981 HOUR <br /> SAMPLING INSPECTION FEE = S 981 HOUR <br /> ALL FEES ARE BASED ON THE$96 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 1221/07) <br />