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0 <br />SAN JOAQUIN COUNTY 0 RECEVED <br />ENVIRONMENTAL HEALTH DEPARTMENT DEC `L 8 2009 <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www..sjgo.v....��.,. ,... RUN%PiENT HEALTH <br />nr0hA1T/(Z•FR\JMES <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />% (Q - -10 r) <br />S"T <br />A fCO a <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />as7! coLj,n4 <br />(Z0q) J39I.-►3c'7 <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />S f -o C I -,f 4 -o n <br />CA <br />0j 4 Gl /e, <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />Ctrl +ce [ Pe i ct l i u rv— <br />S4e \f e_ <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2007 <br />2008 <br />CITY <br />STATE I ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />I ea-� <br />cf 1 q q-,& <br />Closure Installation epair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $345 / TANK <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) <br />PIPING REPAIR FEE = $345 / FACILITY (use for piping, under -dispenser containment, ect.) <br />SAMPLING INSPECTION FEE _ $ 115/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />$ <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 <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $345 / TANK <br /># TANKS X $345 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $345 / FACILITY <br />\LLATION PLAN CHECK <br />Check and Construction Ir <br />TANK ID # <br />PLAN CHECK FEE = $920 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TRANSFER FEE _ $ 20 <br />TANK RETROFIT REPAIR FEE = $345 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades,; <br />S' <br />spill buckets, sumps, misc. <br />PIPING REPAIR FEE = $345 / FACILITY (use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 115/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />SAMPLING INSPECTION FEE _ $ 115/ HOUR <br />ALL FEES ARE BASED ON THE $115 HOURLY RATE. 71ME I HAI txGEEDS FEES vAiu waL BE BILLED O APPUCAN i. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID I AMOUNT RECEIVED I CHECK # RECEIVED BY I DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 07/01/091 <br />