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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTME <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone. (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgpv.org-/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />!�>a%o e -k 4 -on A kka Ctir CJas�- <br />ic rt°e, &v- Wie- <br />FACILITY ADDRESS <br />SITE <br />E^�# WITH AREA COD; <br />34,34 E a Ao-r-rr 4r Ln <br />�(P�HON 95(o—q040 <br />Pt! 1 8 5(ow T® T <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />tt <br />S 7 <br />CA <br />R Sol /a <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />L v <br />ic rt°e, &v- Wie- <br />APPLICAANT MAILING ADDRESS <br />APPLICANT # WITH AREA CODE <br />,91,5',36 W l(,c�0.iyt <br />PHONE <br />A16t— 630 ' <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />Closure Installation Repair Retrofit <br />TANK PENALTY ASSESSED <br />ACTIVE FACILITY <br />TANK ID # (s): CLOSURE FEE = $294 / TANK # TANKS X $294 = <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />Installs as of 8/1/07) <br />$125 PER TANK AFTER FIRST TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />20 06 <br />2007 <br />$ <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 =$24.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): CLOSURE FEE = $294 / TANK # TANKS X $294 = <br />TEMPORARY CLOSURE <br />(Plan Review and inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE _ $294 /FACILITY <br />Check and <br />TANK ID # (s) : I I PLAN CHECK FEE = $784 / FACILITY I $ I <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE _ $294 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc. <br />$ <br />PIPING REPAIR FEE = $294 / FACILITY use for piping, under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 98/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 981 HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 98/ HOUR <br />ALL FEES ARE EASED ON THE i9R 14n111:21 v MATO Tinee Tu eT -----n <br />$ <br />r MMU rvu.L oc au-Lcu f V AFFUCAN 1. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY I DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 08/3/071 <br />