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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.sj og v.or /g ehd <br />FACILITY NAME FACILITY CONTACT NAME <br />Q 0 l IL S -t -t a* 1 Z O <br />FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br />C(3Z 1 TL-40a"k-n" D <br />CITY <br />STATE I ZIP CODE <br />I # OF TANKS AT SITE <br />S TO C-R- -r'0 P4 <br />CA 1 9 S Z O 5 <br />1 -2t <br />APPLICANT BILLING NAME <br />TANK ID # (s): <br />APPLICANT CONTACT NAME <br />IN A, L i Ge C, I, IL SA -al IL4 _ �e C <br />�I l CA A44 <br />APPLICANT MAILING ADDRESS <br />2006 <br />APPLICANT PHONE # WITH AREA CODE <br />Pp. 'QOX lozs� <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />CITY STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />S p -p ICA- <br />Closure Installation Repair etrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE= $315/TANK <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 105/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) <br />$ <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 />TION PLAN CHECK <br />1>GW:<II•�3 <br />PLAN CHECK FEE = $840 / FACILITY <br />$ <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment,oI"L�a—rts,VR upgrade <br />spill buckets, sumps, misc. <br />$ <br />( S <br />PIPING REPAIR FEE = $315 / FACILITY use for piping, under -dispenser containment, ect. <br />$ <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 105/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />$ <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 # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 7/18/08) <br />