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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(5hfloor):(209)468-3433 Web:www.sjgov.org/ghd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ©L) (V- S; /3 z— <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> S To C (/-T-o CA e-7 s Z ( 9 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> P, Q <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> W • A-C R 4 N1 O C Q 9 S 6 q ( Closure Installation Repair Retrofit 5,2 c(3 4 6 7- <br /> - V T <br /> ACTIVE FACILITY <br /> 2000 2001 2002 2003 2004 2005 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK <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=$279/TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,s ill buckets,tank sumps,misc.)$Z <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $93/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR <br /> SAMPLING INSPECTION FEE _ $93/HOUR <br /> ALL FEES ARE BASED ON THE$93 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 I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02/22/05) <br />