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" - SAN JOAQUIN COUNTY 01 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (5`" floor): (209) 468-3433 Web: www.sj oov.or /g ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />r� <br />•�Ci vt L <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />APPLICANT MAILING ADEAESS <br />2004 <br />CITY STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />cS�C-�C�e CA <br />q �5-ZO'l <br />STATE <br />APPLICANT BILLING NAME <br />TANK ID # (s): <br />APPLICANT CONTACT NAME <br />•�Ci vt L <br />2001 <br />C._ 6 f/L <br />APPLICANT MAILING ADEAESS <br />2004 <br />APPLICANT PHONE # WITH AREA CODE <br />(01- C Lo <br />j <br />0� al, 5 -- ) ZC( <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />CiV <br />R j Zf tC) <br />Closure Installation r -Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $279 / TANK <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />2005 <br />$ <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <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 =$24.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $279 / TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />INSTALLAT <br />(Plan Check <br />TANK ID # <br />CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring a ui ment, sill buckets, tank sumps, misc. <br />$ <br />PIPING REPAIR FEE = $279 / FACILITYuse forpiping,under-dispenser containment, ect. <br />$' q <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$ <br />OFFICE USE ONLY <br />SERVICE REQUEST # I FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR I J <br />EH 23 032 (REVISED 02/22/05) <br />