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SAN aTOAQUIN COUNTY <br /> 1 wmoNMENTAL HEALTH DEPARTMENT <br /> 304 Eaf Weber Avenue,3"d Floor,Stockton,CA 95202-2708 <br /> TeWsolte:(209)468-3420.Fox(S'j1dor):(209)4683433 Web:jnny 1sov.ors/ebd <br /> .FACILITY NAME FACILITY CONTACT NAME <br /> SI <br /> FACILITY ADDRESS TE PHONE At WITH AREA CODE <br /> CITY I STATE 21P CODE I #OF TAN KS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> G <br /> APPLICANT MAILING ADDRESS APPUCANT PHONE 9 WITH AREA CODE <br /> VlVL14 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> I Closure installation E ' Retrofits — <br /> ACTIVE RACIUTY <br /> 2000 2001 2002 200$ 2004 2005 <br /> $500 FEE INCLUDES FACILITY FEE*7 TANK <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE■$15/TANK <br /> $ <br /> STATE-SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM®524. 1 FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID (s): CLOSURE FEE-1112791 TANK A TANKS X$279 a <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE-!$2791 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID 0(s); PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK tD#(a); <br /> $ <br /> TANK RETROFIT REPAIR FEE -$2791 FACILITY use for monitoring a ui ment,s III buckets,tank sumps,rrdsc.) <br /> .�" PIPING REPAIR PEE 79!FACILITY use for piping,undeL- ensarcontainment,act. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE = $93/HOUR <br /> UNAUTHORIZED RILEASE EVALUATION FEE $931 HOUR <br /> $ <br /> SAMPLING INSPECTION FEE = $93/HOUR <br /> ALL FE SSARB BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE KILLED TD APPLICANT. <br /> OFFICE USE ONLY <br /> BERVICE REQUE ST# I FACILITY to AMOUNT RECLNVED cHECx�I RECE6V�!BY DATE RECEIVED <br /> SR <br /> EN sat (REVISED ozrrz/M <br />