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0 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.s-jgov.or /g ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />NTT (LF-04z)kj <br />sab-e- <br />FACILITY ADDRESS <br />SITE PHONE #WITH AREA CODE <br />3451J.Sa^ :Toac�-01'1 Sltelt- <br />9ito 992,-4451 <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />S��k <br />CA <br />g52o - <br />$ <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />Ste„lee r fsgvV I,e <br />0', ns B re'>'v) <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />r 3'83 Melfi R1 s,� � a <br />4,0 -46 s - io(pv <br />CITY STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />Pat:AIJmd1 CA- <br />C14954. <br />Closure Installatio Re . Retrofit <br />$ <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 />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 /HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 115/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <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 />INSTALLATION PLAN CHECK <br />TANK ID # (s) : I PLAN CHECK FEE = $920 / FACILITY I $ <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $345 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades,I $ <br />spill buckets, sumps, misc.) <br />12-1--ING REPAIR FEE = $8451 FACILITY (use for pipinq, under -dispenser containment, ect.) I $� <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 115/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 /HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 115/ HOUR <br />— 1— — —.— — 1 nC .vp ... nwV—r 8 1=. 11M= 1 nA I CAM==UJ r==O rAIU YYILL 6C 61LLCU 1 V ArrL1t AN 1 . <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EM Z3 032 (REVISED 07101109) <br />