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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.siggy.orgy/elid <br /> FACILITY NAME I FACILITY CONTACT NAME <br /> FACILITY A13DRESS SITE PHONEJ WITH AREA C@ <br /> L440 W. Df %t(fio Lv4her V)i�i3e. DWI ,�)- -a¢g7 <br /> CITY I a i A i r I #OF TANKS AT SITE <br /> (S +Zy_) CA <br /> APPLICANT BILLIGAJAME APPLICANT—CONTACT NAME <br /> 1'�Ya CfiDrs U^n i <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 3 <br /> NAW M f i - <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Re air Retrofit <br /> - —rACTIVEACILITY2007 2008 20092010..INCLUDES FACILITY FEE+1 TANK(2005-2007) <br /> INCLUDES-FACILITY—FEE+1 TANK(2008-2010) _ _._--.- ._ ._ -$-__-------.__ALTY ASSESSED $ <br /> TANK SURCHARGE=$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=$366/TANK #TANKS X$366= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$366/FACILITY <br /> E <br /> TION PLAN CHECK <br /> k and Construction Inspections) <br /> (s): -- PLANCHECK-FEE�9767-FACIEITY----- - <br /> rREPAJRN CHECK <br /> : <br /> FIT:REPAIR.FEE..=_$366/:FACILITY.(use for monitoring equipment;.cold:starts,.EVR upgrades, $s ill buckets,sum smise.)IR FEE =$366/FACILITY use for piping,under-dispenser containment,ect.) $ <br /> .-MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $122/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $122/HOUR $ <br /> SAMPLING INSPECTION FEE _ $122/HOUR $ <br /> ALL FEES ARE BASED ON THE$122 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 /> SIR <br /> EH 23 032(REVISED 07121/10)' <br />