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SAN JOAQUIN COUNTY 0 ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj og vor /s; ehd FACILITY NAME FACILITY CONTACT NAME Co a r) -i r C I "76 A V4-zA r L eti k-4 et FACILITY ADDRESS SITE PHONE # WITH AREA CODE X575 C� 4 r� div zvq 93Q -/3n 17 CITY STATE ZIP CODE # OF TANKS AT SITE S C.I CA I --1s:Z- -/ Cli APPLICANT BILLING NAME APPLICANT CONTACT NAME ('e a -l-raI P&-ir' 1 e �.(6'�`".- /� O / 1 I ee n I-1 2- ti S c GJ APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE i 17 S'4 ( 9Z -S -,)L162 _ Y o&6 CITY I STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # Plea-scit)WTJI Cli Closure Installation air etrofit S ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $375 / TANK 2006 2007 2008 2009 2010 2011 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) $ PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) $ SAMPLING INSPECTION FEE = $ 125/ HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (";:(?'J:3 2C;` 1 $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED TANK SURCHARGE = $15 / TANK Is STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $375 / TANK # TANKS X $375 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $3751 FACILITY TION PLAN CHECK TANK ID # (s) : I PLAN CHECK FEE = $1,000 / FACILITY REPAIR PLAN CHECK TANK ID # (s) : $ TRANSFER FEE _ $ 25 TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $ spill buckets, sumps, misc. $ PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) MISCELLANEOUS $ TRANSFER FEE _ $ 25 $ CONSULTATION FEE = $ 125/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR $ SAMPLING INSPECTION FEE = $ 125/ HOUR ALL FEES ARE BASED ON THE $125 HOURLY RATE. I imL I HA 1 EAI:EEDS FEES PAID WILL BE GILLED I V AFFUCAlY 1. TOTAL AMOUNT DUE 1 $ -3 75 OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED EH 23 032 (REVISED 08/1/11 by KF)