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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN_ <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(5'hfloor):(209)468-3433 Web:www-sigov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> CN( asc- MhaKE7� <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 419 S. MAIIJ <br /> CITY STATE ZIPCO <br /> DE #OF TANKS AT SITE <br /> �i CA q5 33 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> sacmhe 5 Cil EF ljooDS <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODECIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair etrofit <br /> SZ57'�oL � or <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 2002 2003 2004 2005 2006 2007 <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s): CLOSURE FEE=$285/TANK #TANKS X$285= $ <br /> TEMPORARY CLOSURE <br /> r <br /> an Review and Inspections) <br /> NK ID#(s): TEMPORARY CLOSURE FEE_$285/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$760/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$285/FACILITY (use for monitoring equipment,spill buckets,tank sumps,mise) $ <br /> PIPING REPAIR FEE _$285/FACILITY (use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $95/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE <br /> SAMPLING INSPECTION FEE = $95/HOUR $ <br /> ALL FEES ARE BASED ON THE$95 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> [SERVIC—E—REQUEST# FACILITY ID AMOUNT RECEIVEDCHECK# RECEIVED BY DATE <br /> EH 23 032(REVISED 01/29107) <br />