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• SAN JOAQUIN COUNTY • <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (5 h floor): (209) 468-3433 Web: www.sjRov.orWehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />QUlIC Slop #" 141q <br />M((Ct-7 K/A'i2VF–00"(— <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />-4Z-47— WEST LAticE- <br />(slo) 00 <br />CITY <br />I STATE <br />ZIP CODE <br />I # OF TANKS AT SITE <br />S76C(GT-09( <br />CA <br />9sz(0 <br />3 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />LA/A,0-09 <br />MiC144,F✓c. U Ac.To4 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />F,(). to '4 toiV- <br />343—I(SZ <br />CITY <br />STATE ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />W- S O <br />ICA <br />1 Closure Installation Repair Retrofit <br />� Z g ok 8 4 Z– UT <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 />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 />INSTALLATION PLAN CHECK <br />TANK ID # <br />PLAN CHECK FEE = <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, s ill buckets, tank sumps, misc. <br />$ Z 9 <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 />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED I CHECK # I RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 02122/05) <br />