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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www,sjgov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ^PC:C *#4"=SO .J^4�^t L FL4-r <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> erp 15. L.al 6 .e►v 6 . v¢¢%-+. 0 it 44 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> L.,AwTM41GP CA VIP*$0 3C0t4s 4'bpFtj-Ir <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> G6T11.6 R- Fzlv.owj I N G . t t SPv'Y MC bevre-4 7-1 15 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 4;1.4'7 dO�%6 Rte^ cwt- w-ve j us S s t . -1 Ss 5 5 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> vtJ�•frl N Cwe► fijk4 E5j Closure s allation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2005-2007) 2005 20066 2007 2008 2009 2010 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2010) <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=$49.00/FACILITY $ G <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$366/TANK #TANKS X$366= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$366/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$976/FACILITY <br /> REPAIR PLAN CHECK p <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$366/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets sumps,misc. <br /> PIPING REPAIR FEE _$366/FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $122/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $122/HOUR $ <br /> SAMPLING INSPECTION FEE = $122/HOUR $ <br /> ALL FEES ARE BASED ON THE$122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY 10 AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07121/10) <br />