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r <br /> 02/20/2008 WED 1.5: 25 FAX 2094683433 SJC EHD --- Stockton Sery Sta Eq Co 0007/008 <br /> SAN JOAQUIN COUNTY <br /> F;,'vIRONMENTAL HEALTH DEPAR'T'MENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 PVeb:www..,sjgqy.qrg/gj <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACT/LI�TY[ADURESS r_ SITE PHONE#WITH AREA CODE <br /> vvq qq <br /> CITY _ STATE ZIP CO E _ #OF TANKS AT SITE <br /> IGA----- - <br /> FAPPLIC ILLING NAME APPLICANT CONTACT NAME <br /> km—PLIC-ANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE I CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure installation Repair Retrofit <br /> ACTIVE.FACILITY <br /> !--- � 2003 2004 2005 2006 2007 20Q8 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK <br /> 1 STATE SURCHARGE FOR FACILITIES NOT ALRFADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY <br /> f ERt.,AKEN I CLOSURE <br /> Rer•ov or Permitted Closure in PIa�eL _ i —_— <br /> TANK ID#(si I CLOSURE FEE=$294/TANK= 9 TANKS X$294_ $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK IG#(s): TEMPORARY CLOSURE FEE=$294!FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Cherk and ConstrUCUon Inspections', <br /> TANK ID 1f(s) ---—_ �— PLAN CHECK FEE=$784/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$294!FACILITY (use for monitoring equipment,cold starts,EV radess <br /> spill buckets sum s,mise. <br /> PIPING REPAIR FEF: =$294/FACILITY —(use for Riping,undor-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FF-E _ $20 <br /> CONSULTATION FEE = $98/HOUR _ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 98!HOUR <br /> SAMPLING INSPECTION FEE = S 98/HOUR _ <br /> ALL FEES ARE BASED ON THE$98 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 /> 5R <br /> EH 23 032(REVISED 12131107) <br />