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•i • 1 y • A 1 fi • ' h <br /> s ,e <br /> SAN JOAQUIN COUNTY 00 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web,:www.si ov.ore/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> ,!15 5— cc - -369 ,-: -1 a(k I <br /> CITY STATE ZIP CODE I FF OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> E NE,a S_ncf. I-A") <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2545 k. <br /> It lan"M <br /> CITY STATE I ZIP CODE CIRCLE WORK TO eE DONE CONTRACTOR ICC# <br /> I =man <br /> Closure Installation Re it 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 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 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, ��5 <br /> s ill buckets,sum s,misc. <br /> PIPING REPAIR FEE_$375/FACILITY use for piping,under-dispenser containment,ect. Is <br /> MISCELLANEOUS <br /> rTRANSFER FEE _ $25 $ <br /> SULTATIONFEE _ 5/HOUR $UTHORIZEDRELEASE EVALUATION FEE _ $125/HOUR $PLING INSPECTION FEE _ $125/HOUR $ <br /> ALL FEES ARE BASED ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> E!!E= <br /> =by <br /> EH 23 032(RVISED 08!1/11 KF) <br />