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05-22-06 02:37am From-TAIT ENVI TAL 714-560-8237 T-666 P.03/06 F-995 <br /> y , <br /> SAN JOAQUIIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3'Floor,Stockton,CA 95202-2708 <br /> relephone:(209)468-3420 Fax(efloor):(209)468-3433 Web:www.sjgov.0Mg ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACT TY ADDRESS SITE PHONE 0 WITH AREA CODE <br /> CITY S A ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLIC T PHONE IK WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE BONE CONTRACTOR ICC# <br /> Closure Inttallatl a etrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+t TANK 2000 2001 2002 2003 2004 2005 <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> YANK SURCHARGE_$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 Permltted Closure to Place <br /> TANK ID#W: I CLOSURE FEE_$279/TANK 0 TANKS X$279;= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ections <br /> TANK ID#(s); TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan CtledC and Construction Ins alone <br /> TANK ID# s $ <br /> ( ) PLAN CHECK FEE=$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TAN <br /> ANK RETROFIT REPAIR FIFE _$2791 FACILI use for rnoriftoring equipmtint,s ill w"&.tank sumps.misc.)$ <br /> PIPING REPAIR FEE _$279/FA use for In .under-dispenser containment,ed. Is <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = 031 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FFA _ $93/HOUR $ <br /> SAMPLING INSPECTION FEE a OW HOUR ®� $ <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLER TU APPLICANT. <br /> OFFICE USE ONLY <br /> 3ERVK:E RE 99T# FACILITY ID AMOUNT RECEIVED CHECK,1 I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVI6ED 02/24/05) <br />