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05-22-06 02:37pm From-TAIT ENVIROWENTAL 714-560-8237 T-666 P.03/06 F-995 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Webor Avenue,3'd door,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(5` floor):(209)468-3433 Web:www.sjgov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Af 01 <br /> G24M <br /> FACILITY ADDRESS SITE PHONrm#WrrH AREA CODE <br /> CITY ATE ZIP CODE 1 B OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICAN MAILING ADDRESS APPLICANT PHONE B WrrH AREA CODE <br /> CITY STA E ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation etrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+7 TANK 2000 2001 2002 2003 2004 2005 <br /> $125 PER YANK AFTER FIRST TANK <br /> WANK PENALTY ASSESSED $ <br /> TANK SURCHARGE a$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM m$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure In Place <br /> TANK ID#(s), CLOSURE FEE_$279/TANK #TANKS X 279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review 2nd Ins ectlons <br /> =KID : TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ectlons <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TAN <br /> ANK RETROFIT REPAIR FEE _$279/FACILI use for monitoring ui ment Spill bucW9.tank sum s.mist $ <br /> PIPING REPAIR FEE _$279/FA use for piping.under-dispenser containment,ed. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = 93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 93/HOUR $ <br /> SAMPLING INSPECTION FEE = 93/HOUR $ <br /> ALL FEES ARE BASED ON THE$tai HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLER TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE RE LIE3T# FACILITY ID <br /> AMOUNT RECEIS(ED CHECK#_ _ RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02=105) <br />