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owSAN XbA,QUIN COUN'T'Y <br /> ENVIROt3MENTAi.HEALTH DEPARTIvmENT <br /> 304 Eaef Weber Avenue,311 Floor,Stockton,CA 95202-2708 <br /> Telephone.(209)468-3420 FFax(S'",faoat):(209)4683433 Web:WWW,S]&ay.ars/elad <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE*WITH AREA CODE <br /> CITY STATE 7JP CODE *OF T KS AT SITE <br /> ca <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT.MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> LL V1 114 is —60 3V <br /> CITYI STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> SAL LClosure Installation ¢pa Retraft <br /> ACTIVE FACILITY <br /> 2000 2001 2002 200$ 2004 2005 <br /> $500 FEE INCLUDES FACILITY FEE+9 TANK ". <br /> $925 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE,$151 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM m324.0W FACILITY <br /> PERMANENTCLOSURE <br /> Removal of Permitted Closure in Place <br /> TANK ID ' S ; CLO$URE FEE-3279/TANK A`TANKS X$279 m <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins cticns <br /> TANK ID#(d): =EMPORARYCLOSURF FEE=$2791 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK Ill#Is ; PLAN CHECK FEE_$7441 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK tD# s ; <br /> TANK RETROFIT RE=PAIR FEE $2791 FACILITY use for monitoring a ui ment,split buckets,tank Sumps.mise.) <br /> -•-� PIPING REPAIR FEE 79 I FACILITY use for piping.under-dis ansar containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $20 <br /> CONSULTATION FEE = $93)HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE $9331 HOUR <br /> SAMPLING INSPECTION FEE $931 HOUR <br /> ALL FE6SAPB BASED ON THE$93 HOURLY RATE.71ME THAT EXCEEDS FMS PAID WILL BE 13ItLED TO APPLICANT. <br /> OFFICE USEONLY <br /> SERVICE RECUEST# I FACILITY ID AMOUNT RMEWED CHECK# I RECENED BY DATE RECENED <br /> SR <br /> EH 23 032(REVISED 0=105) <br />