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k s r r► r <br /> +��r + r •:• .+ , r r Yi Y f 'Y �' ii i•Y h4. <br /> r /• ; SY.i�, 1 1f irry; �r I .�;, <br /> ,, i ' •}. ,1...- l' Yap <br /> SAN JQAQUIN COUNTY <br /> ENVIRONMENTAL HEA H DEPARTMENT '" v lc* <br /> 600 East Main Street,Stockton,CA 95202-3029 ' <br /> Telephone:(209)468-3420 Fax:.(2Q9)468-3433 Web:www sigov.ore/ehd r Y' <br /> FACILITY NAME FACILITY CONTACT NAME <br /> C p1 <br /> f r <br /> FACILITY ADDRESS I SITE PHONE#WITH AREA CODE ' <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> ( r <br /> i <br /> CA <br /> APPLICANT BILLING NAME I APPLICANT CONTACT NAME _. <br /> APPLICANT MAILING ADDRESS I APPLICANT PHONE#WITH AREA CODE <br /> 25 <br /> �' _ <br /> CITY STATE ZIP CODE _ CIRCLE WORK TOB -DONE -•-----CONTRACTOR ICC# <br /> _ _.. <br /> Closure Installation R alr Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2006-2007) 2006 2007 2008 2009 2010 2011 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2011). <br /> $125 PER TANK AFTER FIRST TANK . <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGF=$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): CLOSURE FEE $375/TANK #TANKS X$375= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections <br /> TANK ID#(s): PLAN CHECK FEE_$1,000/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE _$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ C' �( <br /> spill buckets,sums misc. 67 J <br /> PIPING REPAIR FEE_$375/FACILITY use for"1 in ,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE <br /> CONSULTATION FEE <br /> ....... $125/HOUR.. .. <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $125/HOUR <br /> SAMPLING INSPECTION FEE _ $125/HOUR $ <br /> ..ALL FEES-ARE BASED ON THE$12S HOURLY RATE. TIME-THAT EXCEEDSFEES A D WILL BE BILLED TO APPLICANT. <br /> TOTAI,AMOUNT DUE <br /> OFFICE-USE.ONLY $ <br /> SERVICE.REQUES## - •FACILITY'ID ":AMOUNT RECEIVED CHECK# RECEIVED BY pATERECEIVED <br /> EH 23 032(REVISED 8141111 by KF) <br />