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3L45t,- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.or FACILITY NAME FACILITY CONTACT NAME -y r C aL_LC_ 4z t 0'54+7 / �vluii S�lx4�'�� b 20 FACILITY ADDRESS SITE PpH2ONE ## WITH AREA CODE / 716 970 3 TO CITY STATE ZIP CODE # OF TANKS AT SITE ISAIDr-k-f-oVx CA q 1:3 hz� j + Closure Installatio Repai Retrofit BILLING NAME APPLICANT CONTACT NAME �APPLICANT � p APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2007 716 970 3 TO CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # VQ . SAL , A-EKRZ Q %&91 Closure Installatio Repai Retrofit ACTIVE FACILITY TANK ID # (s): CLOSURE FEE= $315 /TANK 2004 2005 2006 2007 2008 2009 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR $ 1 $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) $ $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $15 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE= $315 /TANK # TANKS X $315 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $315 / FACILITY INST, Check and Construction TANK ID # (s) : I PLAN CHECK FEE = $840 / FACILITY REPAIR PLAN CHECK TANK ID # (s) : $ $ TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, spill buckets, sumps, misc.) `t $ PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 105/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR $ SAMPLING INSPECTION FEE = $ 105/ HOUR ALL FEES ARE BASED ON THE $1u5 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # I FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 03/20109)