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SAN JOAQUIN COUNTY • ENVIRONMENTAL REALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjg,,ov.or /g ehd FACILITY NAME FACILITY CONTACT NAME N F?, u A- 0 (C :It yS ;I- A -m A-wj�) A A -P P E c i FACILITY ADDRESS SITE PHONE # WITH AREA CODE 98-3 n401:7=A-r T(v (S-30) ovo ( CITY STATE I ZIP CODE # OF TANKS AT SITE {M 4 CA 95-336 1 3 APPLICANT BILLING NAME APPLICANT CONTACT NAME W k G -T—G-A F -C C "Lt5. —2 c �c < C , A ( CIM "'t- W76r t- I o - APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE F'o, 016 34.3 - 1cr-1 CITY STATE ZIP CODE CIRCLE WORK TO BE DONECONTRACTOR ICC # w. C- A / S6 R ( Closure Installation Repair etrofi ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $315 / TANK 2003 2004 2005 2006 2007 2008 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) PIPING REPAIR FEE = $315 / FACILITY use for piping, under -dispenser containment, ect.) UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR $ SAMPLING INSPECTION FEE _ $ 105/ HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) $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 =$24.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $315 / TANK # TANKS X $315 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $3151 FACILITY INSTALLATION PLAN TANK ID # (s) : I PLAN CHECK FEE = $8401 FACILITY REPAIR PLAN CHECK TANK ID # (s) : $ TRANSFER FEE _ $ 20 TAN RETROFIT REPAIR FEE = $3151 FACILITY (use for monitoring equipmen ,cold sta EVR upgrades, / spill buckets, sumps, mise. CONSULTATION FEE _ $ 105/ HOUR PIPING REPAIR FEE = $315 / FACILITY use for piping, under -dispenser containment, ect.) UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE _ $ 105/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR $ SAMPLING INSPECTION FEE _ $ 105/ HOUR ALL FEES ARE BASED ON THE $105 HOURLY RATE. TIME THAT EXCEEDS FF -F-5 PAW WILL BE FsiLLtU TO Ai OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY I DATE RECEIVED SR EH 23 032 (REVISED 7/18/08)