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SAN JOAQUIN COUNTY 46 ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sj og v.org/ehd FACILITY NAME FACILITY CONTACT NAME I"1 N'SS�+ L- C--r> - 426C+k A FACILITY ADDRESS SITE PHONE#WITH AREA CODE IS-73 (2CA) 4? 0 -_ Soo 0 CITY STATE ZIP CODE #OF TANKS AT SITE C"E7GKT O 1� CA C%g5`Li o APPLICANT BILLING NAME APPLICANT CONTACT NAME K A a -Pe 42" .1 Ilk E rJ APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE "19-73 \-4ES-r L.A,-Je ZeF 4,1 to --- S-It 13 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# r� -"4C)'Zj b Closure Installation Repai Retrofit ACTIVE FACILITY 2003 2004 2005 2006 2007 2008 $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2008) $ $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED TANK SURCHARGE=$15/TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID#(s): CLOSURE FEE=$315/TANK #TANKS X$315= TEMPORARY CLOSURE Plan Review and Inspections) TANK ID#(s): TEMPORARY CLOSURE FEE=$315/FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID#(s). PLAN CHECK FEE=$840/FACILITY REPAIR PLAN CHECK TANK ID#(s): $ TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, spill buckets,sumps,misc. PIPING REPAIR FEE _$315/FACILITY (use for piping,under-dispenser containment,ect.) MISCELLANEOUS TRANSFER FEE _ $20 CONSULTATION FEE _ $ 105/HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE _ $105/HOUR $ SAMPLING INSPECTION FEE _ $ 105/HOUR ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK# RECEIVED BY I DATE RECEIVED SR EH 23 032(REVISED 7/18/08)