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SAN JOAQUIN 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.sjgov.or /g ehd <br />FACILITY NAME <br />APPLICANT <br />FACILITY CONTACT NAME <br />0 v t 1C- s -t--o P ?- 6 <br />kU I" A -K t, wA-L -C— " <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />to3o 5. OLI (/E p VE . <br />c& 3-4-3— ((.rz <br />CITY STATE <br />ZIP CODE # OF TANKS AT SITE <br />S -co C IL -t- . f CA <br />- <br />C( S" 2 0 -5 - <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />W 4 ('l &A F—pt C., <br />kU I" A -K t, wA-L -C— " <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE #WITH AREA CODE <br />F" 0, go x loz <br />c& 3-4-3— ((.rz <br />CITY STATE ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />Vv • S f�-f1t"0 C'& Cf S6 -1 ( <br />Closure Installation Repai etrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $294 / TANK <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />Is <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $294 / TANK <br /># TANKS X $294 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />kLLATION PLAN CHECK <br />Check and Construction Ir <br />TANK ID # (s) : I PLAN CHECK FEE = $784 / FACILITY <br />.REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />2 <br />spill buckets, sumps, misc. <br />7 <br />CONSULTATION FEE _ $ 98/ HOUR <br />PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 98/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />ALL FEES ARE BASED ON THE $98 HOURLY RATE. TIME THAT ERGEEUS FEES rAw WILL BE BiLLEL) I V Ar <br />OFFICE U5E ONLY <br />SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED CHECK # RECEIVED BY I DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 12/31/07) <br />