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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton,CA 95202-3029 Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd FACILITY NAME FACILITY CONTACT NAME 13P A(ZLo -vi Leo r` Efo�tc � FACILITY ADDRESS SITE PHONE#WITH AREA CODE I -� l \ YoSevv\.ike Ajev.-ioz— 2ol CITY I STATE ZIP CODE #OF TANKS AT SITE fy�0.r, CA JS 336 3 APPLICANT BILLING NAME APPLICANT CONTACT NAME ERC- " R;-k yYlon-FQ-s o APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# 5 a L QO v�l o C A Closure InstallationRepai Retrofit $2 S2 O — q U f U ACTIVE FACILITY 2003 2004 2005 2006 2007 2008 $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2002-2007) $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2008) $ $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED $ TANK SURCHARGE-$15/TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID# s CLOSURE FEE=$294/TANK #TANKS X$294= TEMPORARY CLOSURE Plan Review and Inspections) $ TANK ID#(s): TEMPORARY CLOSURE FEE_$294!FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) $ TANK ID#(s) : PLAN CHECK FEE_$784/FACILITY REPAIR PLAN CHECK TANK ID#(s): $ TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, spill buckets,sumps,misc. $ PIPING REPAIR FEE _$294/FACILITY use for piping,under-dispenser containment,ect. MISCELLANEOUS TRANSFER FEE _ $20 $ CONSULTATION FEE _ $98/HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE _ $98/HOUR $ SAMPLING INSPECTION FEE _ $ 98/HOUR ALL FEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST N FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED SR EH 23 032(REVISED 12/31/07)