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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: w".sjgov.orglehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />` w <br />- ` <br />FACILITY ADDRESS <br />SITE PHONE #WITH AREA CODE <br />�z.%-k w. C--\.>►.� s -t- ,moa• , �� <br />CW0 '7Qpy-C) <br />CITY STATE <br />ZIP CODE I # OF TANKS AT SITE <br />L—nc� CA <br />CIRCLE WORK TO BE DONE <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />moo.\ +¢ .� . �a S <br />fN \ % Cy- -�S tea--{ v. o 'AL -- <br />,.APPLICANT <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />tt2.4bo <br />(a) I(' S6S16-%oqO <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />{Lp►.rl,r�o Co�r�oJ� <br />CA, <br />G S-7 14 2-1 <br />Closure Installatio Repair etrofIt <br />SEE ?s'�CftiC <br />ACTIVE FACILITY <br />TANK ID # s : <br />CLOSURE FEE = $345 / TANK <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) <br />PIPING REPAIR FEE = $345 / FACILITY use for piping, under -dispenser containment, ect. <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />SAMPLING INSPECTION FEE _ $ 115/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # s : <br />CLOSURE FEE = $345 / TANK <br /># TANKS X $345 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $345 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TRANSFER FEE _ $ 20 <br />TANK RETROFIT REPAIR FEE = $345 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />'3'AJS <br />spill buckets, sumps, misc. <br />CONSULTATION FEE _ $115/ HOUR <br />PIPING REPAIR FEE = $345 / FACILITY use for piping, under -dispenser containment, ect. <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $115/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />SAMPLING INSPECTION FEE _ $ 115/ HOUR <br />ALL FEES ARE BASED ON THE $115 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # IFACILITY ID AMOUNT RECEIVED I CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 07/01109) <br />00 <br />