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0 SAN JOAQUIN COUNTY 0 <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 />Arco .2130 <br />Scort L--.S-rC4r <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />7906 W. C 1 Dorado <br />2 9.s 7 -.Z5P7 <br />CITY <br />STATE <br />ZIP CODE I # OF TANKS AT SITE <br />Sfioch'ten <br />CA <br />ys-2) 1 3 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />e-ttler- P.nc,., Int. <br />I?c,ndy Frown <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />3lYO601j CcimaL7r. SL).'Ie- 170 <br />/b ?6 6 4-?? <br />CITY STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />t <br />ILgr1 ChD Cl'2�CJO✓q CG, <br />9S6 )v <br />Closure Installation epair etrofit 5.2- -cs.2 — 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 (2004-2007) <br />PIPING REPAIR FEE = $345 / FACILITY (use for piping, under -dispenser containment, ect. <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />SAMPLING INSPECTION FEE _ $ 115/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />Is <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ 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 />PLAN CHECK FEE = $920 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : F'11 s c.11" t P COnA # A 1 8 <br />TRANSFER FEE _ $ 20 <br />TANK RETROFIT REPAIR FEE = $345 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, misc. <br />CONSULTATION FEE _ $ 115/ HOUR <br />PIPING REPAIR FEE = $345 / FACILITY (use for piping, under -dispenser containment, ect. <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 115/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />SAMPLING INSPECTION FEE _ $ 115/ HOUR <br />ALL FEES ARE BASED ON THE j115 HOUKLY NATE. TIME THAT EAGEEDS FEES PAID WILL tit BILLEU 1 O APPLIGAN 1. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 07/01/09) <br />