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777 Ada -201'�- SAN JOAQUIN COUNTY •. ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. Hazelton Ave., Stockton, CA 95205-6232 Tel4hone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjohd.com FACILITY NAME APPLICANT CONTACT NAME FACILITY CONTACT NAME PHONE # WITtH''jAREA CODE 035 W R /.moi P 16�• ZIP CODE CIRCLE WORK TO BE DONE AGILITY ADDRESS $ SITE PHONE #WITH AREA » 5 -625 CITY I STATE ZI CODE # OF TANKS AT SITE CA Ili M fl, APPLICANT BILLING NAME APPLICANT CONTACT NAME APPLICANT MAILINADDRESSAPPLICANT PHONE # WITtH''jAREA CODE 035 W R /.moi P CITY i STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # $ Closure Ins tion Re it Retrofit ACTIVE FACILITY TANK ID # s : CLOSURE FEE _ $390 /TANK 2009 2010 2011 2012 2013 2014 $ $550 FEE INCLUDES FACILITY FEE + 1 TANK $130 PER TANK AFTER FIRSTTANK $ $ TANK PENALTY ASSESSED TANK SURCHARGE= $15 / TANK $ STATE SURCHARGE FOR FA ILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY PERMANENT C1.LOSURE Removal or Permitted Closure in Place TANK ID # s : CLOSURE FEE _ $390 /TANK # TANKS X $390 = TEMPORARY' CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $3901 FACILITY L� REPAIR PLAN CHECK TANK ID # {s) $ TANK RETROFIT REPAIR FEE _ $3901 FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $�4 spill buckets, sumps, misc. 5J t PIPING REPAIR FEE = $390 / FACILITY use for piping, under -dispenser containment, act $ MISCELLANEOUS TRANSFER FEE _ $ 25 $ CONSULTATION FEE _ $ 1301 HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 130 1 HOUR $ SAMPLING INSPECTION FEE = $130/ HOUR FEES ARE BASEDON THE 5730 HOURLY RATE TI $ ME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. TOTAL /1MOUNT DUE is OFFICE USE ONLY SERVICE REQUESTS I FACILITY ID AMOUNT RECEIVED I CHECK #RECEIVED BY DATE RECEIVED EH 23 032 (DEVISED 08-04-94)