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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.sigov.or <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />aI-Pv-o (0yI <br />Sa f\d <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />210E N.t,M r L AJ <br />CITY <br />I STATE <br />I ZIP CODE I # OF TANKS AT SITE <br />!LZ"O <br />CA <br />qs- 3 Ll <br />APPLICANT BILLING NAME <br />TANK ID # (s): <br />APPLICANT CONTACT NAME <br />r, <br />+ <br />''v <br />rah 0 h.n-ct- <br />APPLICANT MAILING ADDRESS <br />2009 <br />APPLICANT PHONE # WITH AREA CODE <br />2S60 <br />Sa° ud <br />4 O <br />3 `17S^9/y/ <br />CITY <br />F <br />I STATE I ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />JQ(1 <br />CCU -L <br />19S -W& Z <br />Closure Installation a a'- Retrofit 2 2 -LY (� <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE= $315 /TANK <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />SAMPLING INSPECTION FEE _ $ 105/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) <br />$ <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 IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE= $315 /TANK <br /># TANKS X $315 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $315 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : <br />PLAN CHECK FEE = $840 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, misc. <br />PIPING REPAIR FEE = $315 / FACILITY use for piping, under -dispenser containment, ect. <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 105/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />SAMPLING INSPECTION FEE _ $ 105/ HOUR <br />ALL FEES ARE BASED ON THE $105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # I FACILITY ID AMOUNT RECEIVED CHECK # I RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 03/20/09) <br />