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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.sjaov.or /g ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />04 rc o 2130 <br />S Co yr L; S to r <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />790 & ,t/. E l #� or -Ad O -S7- <br />7o On IS 7 2 9 e 7 <br />CITY <br />I STATE <br />ZIP CODE I # OF TANKS AT SITE <br />SToc-Kfon <br />I CA CO • <br />cls- 2la <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />GetrIer - iZ-aan !n c• <br />ec%nd y QI'cDwn <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />3110 Golc) Cc►MP Int'. SO-'te- /7C <br />9/6 P-26 6 P2S- <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />V-C4nCh0 Cordcova <br />jCcj. <br />19S bin <br />Closure Installation EEE)Retrofit <br />523boSSz-vT <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 />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) <br />$ <br />PIPING REPAIR FEE = $345 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />SAMPLING INSPECTION FEE = $ 115/ HOUR <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 =$49.00/ 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 CHECF <br />(Plan Check and Construction I <br />TANK ID # (s) : <br />PLAN CHECK FEE = $920 / FACILITY <br />REPAIR PLAN CHECK <br />TANKID#(s): Cij STP Sump Sensor Conf 4 5 <br />$ <br />TRANSFER FEE _ $ 20 <br />$tlm <br />TANK RETROFIT REPAIR FEE = $345 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, misc. <br />$ <br />PIPING REPAIR FEE = $345 / FACILITY (use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />$ <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 AKt LsAJty UN 1 Ht $115 HUUKLY KATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST 11FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 07/01/09) <br />