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SAN JOAQUIN COUNTY <br /> ENVIRONMI-XI-AL HEALTH DIPARTNIFNT <br /> 1868 E.flazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www. kov.c)rg/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> KCA�S e A -0-Att: Fu Her <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 76 -20W <br /> STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLIGANT MAILING DRESS APPLICANT PHONE III WITH EA CODE <br /> Pa. 80.y :2301 2S Z -Iv <br /> CITY CIRCLE WORK TO BE DON- <br /> Closure Installation e�#a® Retrofit –^ __l. �___._._I <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+I TANK(2007-2008) 2008 2009 2010 011 012 2013 <br /> S550 FEE INCLUDES FACILITY FEE+I TANK(2009-2012) <br /> — <br /> S125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> _TANK SURCHARGE_=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CLIPA PROGRAM=535.00(FACILITY <br /> PERMANENT CLOSURE <br /> --En2,yal or Permitted Closure in Place) <br /> CLOSURE FEE=S375(TANK #TANKS X$375 <br /> TEMPORARY CLOSURE <br /> (Plan Review and Lnsj)eclJons) <br /> TANK ID#(s) TEMPORARY CLOSURE FEE=$3751 FACILITY <br /> INSTALLATION PLAN CHECK <br /> fP"ljI,a!jCChecMlk,and Const ti I t ns) <br /> TANK ID#(s) PLAN CHECK FEE=$10001 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades. $ <br /> spill buckets,sumps,mise} <br /> PIPING REPAIR FEE =$375/FACILITY (use for piptngunder-dispenser Containment $ <br /> MISCELLANEOUS <br /> TRANSFER FEE $25 <br /> CONSULTATION FEE = $1251 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 1251 HOUR $ <br /> SAMPLING INSPECTION FEE $1251 HOUR $ <br /> ALL FEES ARE BASED ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT IVIED I CHECK III RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED IIIW2013 by KF) <br />