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• 1 • <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, P Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (5'hfloor): (209) 468-3433 Web: www.sigov.or <br />FACILITY NAME <br />FACILITY CONTA T NAME <br />Ari / GCA // <br />a <br />FACILITYADDRESS <br />SITE PHONE # WITH AREA CODE <br />��y/}� <br />� <br />//yf <br />CITY <br />I STATE <br />I ZIP CODE I # OF TANKS AT SITE <br />1<4 .,1 J <br />CA <br />I Closure Installat' n Repa' Re ofit <br />APPLICANT 9ILLING NAME <br />APPLICANT CONTACT NAM <br />,,���m�� <br />2000 <br />APPLICANT MAILING ADDRESS rAPPLICANT <br />PHO #WITH R A CODE <br />2003 <br />2004 <br />CITY <br />STATE I ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />1<4 .,1 J <br />e 5',94b - <br />I Closure Installat' n Repa' Re ofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $279 / TANK <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />2005 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />is <br />SAMPLING INSPECTION FEE = $ 93/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $279 / TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />kLLATION PLAN CHECK <br />Check and Construction Ir <br />TANK ID # <br />PLAN CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />is <br />SAMPLING INSPECTION FEE = $ 93/ HOUR <br />ALL FEES ARE BASED ON THE $93 HOURLY RATE. i WE T HA i EXCEEUS FEES FAw WILL BE BiLLEu i v AFFUUAN i. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 02122/05) <br />