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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.sjeov.ore/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />,J35 ��Ero % fJiil's itsi& <br />ZM- X114 - 55-1(o <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />( -253 V cfvrd <br />CITY STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />Cid i CA <br />Q62- 0 <br />.ft)n <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />p�,g_, <br />2004 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE #'WIT AREA CODE <br />2-6:313 W c v/a m Dr- <br />401-b3--5-7 <br />CITY ka <br />STAT <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />.ft)n <br />q5' <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $315 / TANK <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />-%,' <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2003-2008) <br />$ <br />PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />SAMPLING INSPECTION FEE = $ 105/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <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 />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $315 / TANK <br /># TANKS X $315 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $315 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : PLAN CHECK FEE = $840 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />fs <br />spill buckets, sumps, misc.) <br />-%,' <br />$ <br />PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 105/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 105/ HOUR <br />M---- DMOMU Ulv 1 nc . IUD MUUKLT KAI L. I UVIt I MAI tRl:ttUJ Mt:b VAIU WILL Ut 5ILLtU I U AYYLIGAN I. <br />OFFICE USE ONLY <br />