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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEAW <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fay(209)468-3433 Web.www.sj y.o ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> TIA Il V A <br /> FACILITY ADDRESS SITEPHONE##WW,TTH AREA CODE <br /> �/ <br /> CITY STATE ZIP CODE #OF TANATE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> El <br /> C. <br /> APPLICANT MAILING ADDRESS JAPPLICANTPHONE# AREA CODE <br /> CITY <br /> STATE I ;ZIP—CODECONTRACTOR ICC# <br /> Closure Installation RNRair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2006 2007) 2006 2007 2008 2009 2010 2011 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(200&2011) <br /> $125 PER TANK AFTER FIRST TANK $ . <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$375/TANK #TANKS X$375= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Conshuction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$1,000/FACILITY $ <br /> FTANK <br /> AIR PLAN CHECK <br /> ID#(s): <br /> RETROFIT REPAIR FEE _$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> s 'il buckets,sum s,mist. `� <br /> PIPING REPAIR FEE_$375!FACILITY use for piping,under-dispenser containment,ect. $ <br /> rSAMPUNG <br /> OUS <br /> E _ $25 $ <br /> ON FEE = $125/HOUR $ <br /> ED RELEASE EVALUATION FEE _ $125/HOUR $ <br /> PECTION FEE _$125/HOUR $ <br /> ALL FEES ARE BASED ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> -TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST FACILITY ID11 AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 08MM1 by KF) <br />