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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sieov.ore/ehd <br />FACILITY NAME <br />TANK ID # (s): <br />FACILITY CONTACT NAME <br />2007 <br />2008 <br />C <br />FACILITY ADDRESS <br />2011 <br />SITE PHONE # WITH AREA CODE <br />�,D`-kaS <br />�J � . <br />( 'Dt�c Za- —Y�L-co <br />CITYY�. <br />LP CODE <br />STATE <br />MP CODE # OF TANKS AT SITE <br />J"\ c�4G �.�.-� <br />'3S -i c S <br />CA <br /><:k x-0-1 <br />APPLICANT BILLING NAME <br />TANK ID # (s): <br />APPLICANT CONTACT NAME <br />2007 <br />2008 <br />2009 <br />APPLICANT MAILING ADDRESS <br />2011 <br />APPLICANT PHONE # WITH AREA CODE <br />��o� Ch4ll z.-� �•" <br />�J � . <br />S?0 53a - L-F'l cmc <br />CITY STATE <br />LP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />'3S -i c S <br />Closure Installation a ai'r etrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />2012 <br />$ <br />$500 FEE INCLUDES FACILITY FEE+ 1 TANK (2007-2008) <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser Containment, act. <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE =$15/TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br /># TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, mist. <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser Containment, act. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />$ <br />ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE $ <br />