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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.sjgov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />T-exkart lard <br />S'te-ve SC,% m vn <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />1.20 Circle <br />916 3 6 •3767 <br />CITY STATE <br />ZIP CODE I # OF TANKS AT SITE <br />-t ejeu^ CA <br />/s.206 1 .3 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />et•+le�- 9-nan Inc. <br />R" 5 t3itv&jn <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />attic Cm C* Or. SU:fc t70 <br />� <br />CITY STATE 2IP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />f✓ CX.. s 6 70 <br />Ciosure Installadon e� Retrofit <br />?SO -4L 3-V T <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $345 / TANK <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (20042007) <br />$ <br />PIPING REPAIR FEE = $345 / FACILITY use for piping, under -dispenser containment, act. <br />$ <br />1 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) <br />$ <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 =$49.001 FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $345 / TANK <br /># TANKS X $345 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $345 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : <br />I PLAN CHECK FEE = $920 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : yeS&r &dft CIO Id slur -T. O S'% <br />$ <br />TRANSFER FEE _ $ 20 <br />TANK RETROFIT REPAIR FEE <jjACILITY (use for monitoring equipment, starts EVR upgrades, <br />3 &is - <br />spill buckets sumps, misc. <br />$ <br />PIPING REPAIR FEE = $345 / FACILITY use for piping, under -dispenser containment, act. <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $115/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE =$115/HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 115/ HOUR <br />ALL FEES ARE BASED ON TRE *110 ROURLT RATE. TIME TRAT EXUCIU S FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST f FACILITY ID I AMOUNT RECEIVED I CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED OT101/09) <br />