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SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL,ri-I DEPARTMENT 600 F_,ast Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: w«-«.sigov.ora/ehd FACILITY NAME FACILITY CONTACT NAME IIQ t bje!s A(`f✓1GZ /�t/rIGS Li1C� FACILITY ADDRESS SITE PHONE # WITH AREA CODE 2006 � �� 444kt CITY STATE ZIP CODE # OF TANKS AT SITE �r �T-Dc k CA F -5-'?! 9 X09 -5-3 -93p4� APPLICANT BILLING NAME TANK ID # (s): CLOSURE FEE = $294 / TANK APPLICANT CONTACT NAME 10;1\ fL,e. ?0,', c-0 . 2006 � �� 444kt APPLICANT MAILING ADDRESS $500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) APPLICANT PHONE # WITH AREA CODE 280_S Pd(-ond �v�; X09 -5-3 -93p4� CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # c 9.5-3o9 Closure Installation Repai Retrofit j`Z 23AIU-0 j ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $294 / TANK 2003 2004 2005 2006 2007 2008 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) $ PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect.) $ SAMPLING INSPECTION FEE = $ 98/ HOUR $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 PERMANENT CLOSURE (Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $294 / TANK # TANKS X $294 = TEMPORARY CLOSURE (Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $294 / FACILITY INSTALLATION PLAN CHECK (Plan Check and Construction Ir TANK ID#(s): PLAN CHECK FEE = $784 / FACILITY REPAIR PLAN CHECK TANK ID # (s) : $ TRANSFER FEE _ $ 20 $ TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $ spill buckets, sumps, misc.) $ PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect.) MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 98/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 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 23032 (REVISED 12/31/07)