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SAN JOA <br /> � QUIN 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.sjvov.org/ehd <br /> FACILITY NAME I FACILITY CONTACT NAME <br /> FACILITY ADDRESS <br /> SITEPRONE#WITH EA CODE <br /> v _. <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLI T MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> OV <br /> 4e ALL M- MA <br /> � ® <br /> .CITY I STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> VC I Closure Installation Re 'r Retrofit <br /> rACTIVETY <br /> DES FACILITY FEE+1 TANK(2006-2007) 2005 2007 2008 2009 2010 2011 <br /> DES FACILITY FEE+1 TANK(200&2011) <br /> AFTER FIRST TANK $ <br /> LTANK <br /> PENALTY ASSESSED $ <br /> SURCHARGE=$15/TANK $ <br /> SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY 14A 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=$3751 FACILITY <br /> IINSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANKID#(s): ._PLAN CHECK FEE_$1,000.1 FACILITY <br /> FREPAIR PLAN CHECK <br /> KID#(s): <br /> K.RtROF1T REPAIR FEE —$375/FACILITY use for moriiton( ng equipment,cold starts,EVR upgrades, <br /> s ll buckets,sum mG REPAIR FEE= 75/FACILITY use for i ,under-d' containment,ect $ <br /> -MISCELLANEOUS.—_ <br /> TRANSFER FEE _ $25 $ <br /> =CONSULTATION <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $125/HOUR $ <br /> SAMPLING INSPECTION FEE _ $125/HOUR $ <br /> ALL FEES ARE BASE()ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID VYILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH'23 032(REVISED 08/1/11 by KF) <br /> I <br />