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rSAN JOAQUIN COUNTY 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />EseWD-V-\ Min' <br />12W 5N )2 <br />FACILITY ADDRESS <br />SITE PHONE # WI AREA CODE <br />to P Nose -mils -r- <br />) s &t- Iito <br />CITY <br />STATE <br />ZIP CODE <br />I # OF TANKS AT SITE <br />ca'vc)O i <br />CA <br />-S32� 0 <br />$ <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />EseWD-V-\ Min' <br />12W 5N )2 <br />APPLICANT MAILING -ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />olvnIcl- A 5 O, el <br />t <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />$ <br />Closure Installation Re air Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $390 / TANK <br />2010 <br />2011 <br />2012 <br />2013 <br />2014 <br />2015 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK <br />$ <br />PIPING REPAIR FEE = $390 / FACILITY use for.pi ping, under -dispenser containment, ect. <br />$ <br />SAMPLING INSPECTION FEE = $ 130/ HOUR <br />$130 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $390 / TANK <br /># TANKS X $390 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $390 / FACILITY <br />ILLATION <br />Check anc <br />TANK ID # (s) : I PLAN CHECK FEE = $10401 FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TRANSFER FEE _ $ 25 <br />TANK RETROFIT REPAIR FEE = $390 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />�� v <br />spill buckets, sumps, misc. <br />$ <br />PIPING REPAIR FEE = $390 / FACILITY use for.pi ping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 130/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 130 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 130/ HOUR <br />FEES ARE BASED ON THE $130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE $31 b <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 04-22-15) <br />