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I, . ....... .................. RECEIVED <br /> SAN JOAQUIN COUNTY. JAN 16-`203 <br /> EsNY..IRONMENTAL HEALTH.DEPARTMENT <br /> 1868 E.Htiielton Ave.,Stockton;CA 95205-6232 <br /> Telephone (209)468-3420 Fax:(209)468-3433 Web:www.s'ce <br /> 6WA <br /> FACILITY NAME <br /> ..PAGt4:lTY CONTACT NAM1E. <br /> _ .. _... _ <br /> F LTTY,ADDRESS :SITE PHONE#WITH AREA CODE <br /> l . .. <br /> STATE ZIP CODE #OF TANKS AT SITE <br /> -APPLICANT BILLING NAME APPUCAN T CONTACT NAME.' <br /> APPLICANT MAILING ADDRESS, APPLICANT PHONE#WITH AREA CODE <br /> 'CITY t STATE ZIP CODE CIRCLE VORKnBE DONE I CONTRACTOR ECC# <br /> Closare ins Non R air Retrofit <br /> ACTIVE FACILITY <br /> 2007 2008 2009 2010 2011 2012 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2067-2008) <br /> $550 FEE INCLUDES FACILITY FEE+•1 TANK(2009-2012) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> —TANK—SURCti6&GE=_$1El_TANK.--- _.___ _..__... ___.._.._ _ <br /> STATE.SURCHARGE FOR FACILITIES NOTALREADY ON INVENTORY INA CUPA PROGRAM=$49.001 FACILITY <br /> PERMANENT.CLOSURE <br /> Removal or Permitted Closure in Place <br /> T .IIR:# & CLOSURE FEE_$3751 TANK ' #TANKS X 375= <br /> TEMPORARY CLOSURE <br /> TANK ID.#(s): TEMPORARY CLOSURE FEE_$3751 FACILITY <br /> INSTALLATION PLAWCHECK . <br /> Pian Check and Construction t ect orm <br /> Pt AN`CHECK FE€-$90007 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> "IAPlKRETROFIT REPAIR FEE ='$375/FACILITY(use for'mbnitoiing equtprret,ild starts,EVR upgrades, fir' <br /> ,...s iii-buckets sums misc.)- - <br /> PIPING REPAIR FEE = 75!FACILITY use for pipfrig,under-dispenser containment ect. <br /> MISCELLANEOUS <br /> -TRANSEER,FEE. .....-.:. .25 <br /> ..CONSULTATION FEE = 1251 HOUR <br /> 6NAUTtiORiZED RELEASE EVALUATIOPI EEE = 125%NOUR <br /> -SA'AMPJ ING INSPECTION.FEE $1251:HQUR,: $ <br /> _:,._. ....... . .._..:.. .._AMFEES'ARE'USED-ON'THE`5`WHOt1RLY RATE:TtME THAT EXCEEDS FEESPA1D WlLL.SE BILLED TO APPLICANT:' <br /> TOTAL AMOUNT DUE $ <br /> =CFi�GK <br /> EH 23 032(REVISED 04 W12 by KF1 <br /> __......,. ......... ...._.......... <br /> _ _ ........... ._....._. <br />