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• SAN JOAQUIN COUNTY 6 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />QU I1L S -rap t7 /3z <br />YM lCo A-t't A c ->—o'( <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />3 S S' - W, 4 A -vin w� roti � u. <br />/G 3a -3—((Y-' <br />CITY STATE <br />ZIP CODE I # OF TANKS AT SITE <br />S'ro c rz -re CA <br />9 S-?- I 3 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />r" F -Kr, 1'-c ,z /'� r, , <br />YM lCo A-t't A c ->—o'( <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />?'G. ?C�(- (oz.s' <br />/G 3a -3—((Y-' <br />CITY <br />I STATE <br />ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />J, SSC O <br />C A <br />q ?-6 a t Closure Installation Repairetro , <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $315 / TANK <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) <br />SAMPLING INSPECTION FEE _ $ 105/ HOUR <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 />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): <br />CLOSURE FEE = $315 / TANK <br /># TANKS X $315 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $315 / FACILITY <br />Check and Construction I <br />TANK ID # (s) : I PLAN CHECK FEE = $840 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TRANSFER FEE _ $ 20 <br />TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, id starts, EVR upgrad <br />/ S <br />spill buckets, sumps, misc. <br />PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 105/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />SAMPLING INSPECTION FEE _ $ 105/ HOUR <br />ALL FEES ARE BASED ON THE $105 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 7/18/08) <br />