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• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sIgov.ori/ehd FACILITY NAME FACILITY CONTACT NAME bZJL C '�'�7 0 J`i'm} jvtc-- vz . FACILITY ADDRESS SITE PHONE # WITH AREA CODE v4I -.- Lcl-�I t '1-. 4�1 — t L L CITY STATE ZIP CODE I # OF TANKS AT SITE il CA Q6ZO9 leytcr—w Cid UY) APPLICANT BILLING NAME APPLICANT CONTACT NAME Da'e SS � � •c c vc� ��' vl�S�i' �'t Lr S �4 N'l-t" /7k k 4y 0 APPLICANT MAILING ADDRESS APPLI ANT PHONE # WITH AREA CODE 2009 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # c cIIC. t 4 �, $550 FEE INCLUDES FACILITY FEE + 1 TANK (20=08-2009) $125 PER TANK AFTER FIRST TANK Closure Installation Repair 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) UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR SAMPLING INSPECTION FEE _ $ 105/ HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (20=08-2009) $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 INSTALLATION PLAN CHECK Plan Check and Construction Inspections) 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. PIPING REPAIR FEE = $315 / FACILITY use for piping, under -dispenser containment, ect. 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 $105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 03/20/09)