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�-� :.rr rf h f . r• x , ,y Y .,`, rYCtiW y .�i' .�,�:r} r 1 rr 1 1 h r" Ilr / I�e,.,� !+{. <br /> F :"r �Y', r f Mf f r r rr�h" „4� . i''r +�'� ► r Yf ti r t v.r a{i,�W"�K . <br /> f SAN JQAQUIN COUNTY / �� ' <br /> ENVIRONMENTAL HEALTH DEPARTMENT l J <br /> 600 East Main Street,Stockton,CA 95202-3029 ' <br /> Telephone:(2.09)468-3420 Fax (2Q9)468-3433 Web:www.sigov.org/ehd <br /> ' <br /> FACILITY NAME FACILITY CONTACT NAMe. <br /> h <br /> FACILITMADDRESS SITE PH E WITH AREA CODE <br /> V~36 6 . <br /> CITY Sl'ATE Z P CQDE #OF TANKS AT SITE " <br /> h r <br /> CA g ' <br /> o— r <br /> APPLICANT BILLING NAME APPLICANT CQNTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 25 <br /> CITY V <br /> STATE YIP CODE _ CIRCLE.WORK_TO-BE.DOnVE In <br /> NE- -- CONTRACTORiCC# <br /> - _ <br /> Closure Installation R air Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2066-2007) 2006 2007 2008 2009 2010 2011 <br /> $550 FEE INCLUDES FACILITY FEF_+1 TANK(2008-2011) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGF.=$15/TANK $ <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): CLOSURE FEE $375/TANK #TANKS X$375= $ <br /> 'TEMPORARY CLOSURE <br /> Pian Review and Ins ections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections <br /> TANK ID#(s): PLAN CHECK FEE=$1,000/FACILITY $ <br /> r�ti­ <br /> PAN CHECK <br /> #(s)_d _ — _—-—---ROFIT REPAIR FEE $375/FACILITY (use for monitoring equipment,cold starts,EVR upgradesspill buckets sumps misc)REPAIR FEE_$375/FACILITY use forpiping,under-dispenser containment,ect. $ <br /> . <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 <br /> _CONSULTATION FEE _ _ . <br /> $125/HOUR- <br /> . _. $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $125/HOUR $ <br /> SAMPLING INSPECTION FEE - $125/HOUR $ <br /> ALL FEES ARE BASED ON THE$1YS HOURLY RATE: TIME'rHAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL,AMOUNT DUE <br /> OFFICE USE ONLY $ <br /> _ SERVICE REQUEST# FACILITY ID <br /> AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 43 032(REVI§E6 081/11 by KF) _ _ — <br />