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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj og v.or /g ehd <br />FAClL9Y NAM <br />APPLICANT CONTACT NAME <br />FACT Y CONTACT NAM <br />e Z.rn <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITHCODE <br />FACILITY ADDRESS <br />2007 <br />SITE PHONE #WITH ARFklronF <br />�0 �z <br />�p <br />I�i'1 ` <br />Oc�))L � <br />CITY <br />STATE <br />ZIP CODE # OF TANKS AT SITC�l <br />Closure Installation Repair rofit <br />CA <br />y /\ <br />` —Sa4b <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />\'� <br />e Z.rn <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITHCODE <br />2006 <br />2007 <br />AREA <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />Closure Installation Repair rofit <br />ACTIVE FACILITY <br />TANK ID # (s) : <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />SAMPLING INSPECTION FEE _ $ 105/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) <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 <br />CLOSURE FEE = $315 / TANK I # TANKS X $315 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : TEMPORARY CLOSURE FEE = e "' FACILITY <br />11z6�t_14w_"t1[oL`lC7Alla <br />TANK ID # (s) : I PLAN CHECK FEE = $840 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE _ / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, misc.)YY.•���✓ <br />CONSULTATION FEE _ $ 105/ HOUR <br />PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 105/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />SAMPLING INSPECTION FEE _ $ 105/ HOUR <br />ALL ttt5 AKt bAStU UN I tit ;�Wb HUUKL7 KAI t. I IMt I HAI tACCcw rr-r,I-AIIJ vnLL aC oiLLMU I Ur rrW�Ml ry I. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY I DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 7/18/08) <br />