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Dec..22 09 12:22p El itTV Contactors 120946 v w 42 <br />SAN JOAQIUIN COUNTY <br />EWWRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj o� v.om/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />CLOSURE FEE = $345 / TANK <br />CITY <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CQDE <br />o <br />ZIP CODE I # OF TANKS AT SITE <br />CITY I STATE <br />�— CA <br />M2a,2 I j <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />vl <br />APPLICANT MAILING ADDRESS APPLICANT PHON WITH AREA CODE <br />CLOSURE FEE = $345 / TANK <br />CITY <br />STATE <br />ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />2007 <br />2008 <br />Closure Instftion Repair Retrofit <br />ACTIVE FACILITY <br />TANK 10 # (s): <br />CLOSURE FEE = $345 / TANK <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />$ <br />S500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) <br />1 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2000) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY 1N A CUPA PROGRAM =$49.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Plate <br />TANK 10 # (s): <br />CLOSURE FEE = $345 / TANK <br /># TANKS X $345 = <br />TEMPORARY CLOSURE <br />Pian Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $345 / FACILITY <br />PLAN <br />TANK ID # <br />PLAN CHECK FEE = $9201 FACILITY <br />REPAIR PLAN CHECK <br />TANK ID#(s): <br />TANK RETROFIT REPAIR FEE = $3451 FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sums misc. <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />PIPING REPAIR FEE = $3451 FACILITY use for pipinR, under-dis enser containment, act. <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE S20 <br />$ <br />CONSULTATION FEE = $ 115/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 1151 HOUR <br />W 1 RCCS ECC QACOM nu — cane —.., v -.Tr •...� �...� �......��.. ____ _ ___ ._.... __ __.. __. <br />$ <br />. r -.v . rua ...._., — ..— 1 V Hrr Ll4jim 1. <br />OFFICE USE ONLY <br />SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED 17HECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 07101109) <br />