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SAN JOAQUIN COUNTY • <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br />Telephone. (209) 468-3420 Fax (S`" floor): (209) 468-3433 Web: www.si og v.org/ehd <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />,^^ <br />13O --L (_ Arlt_ rV , �2/G�� 3 <br />A <br />FACILITY ADDRESS <br />2004 <br />AREA CODE <br />SITE PHONE # WITH <br />P Box ioZs— <br />t6 3�- 3 - (r -,-- <br />CITY STATE ZIP CODE <br />/ s W 2. A -►-T Lr <br />Z D <br />CA <br />CIN I <br />STATE <br />ZIP CODE # OF TANKS AT SITE <br />TR A- c <br />I CA <br />1 s3 } 6 3 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />V/ /1 L To wk G�C, I K(E ISR. I, a C� . J�;k r - <br />/ y ` I C 94 A-9,1- WA- C T IR4 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2004 <br />2005 <br />P Box ioZs— <br />t6 3�- 3 - (r -,-- <br />CITY STATE ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />S—p <br />CA <br />if S6 q I <br />Closure lnstallation epair Retrofit <br />S' 2 `l e ry 2 - V <br />ACTIVE FACILITY <br />Removal or Permitted Closure in Place <br />TANK ID # s <br />2001 <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />SAMPLING INSPECTION FEE _ $ 95/ HOUR <br />1T riser CVf c=ne cFFc Fnln WILL BE BILLED TO APPLICANT. <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $285 / FACILITY <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # s <br />$Z <br />TANK RETROFIT REPAIR FE _ $285 / F CILITY (use for monitoringequipment, spill buckets, tank sumps, misc.) <br />TANK ID # (s): <br />CLOSURE FEE = $285 / TANK <br /># TANKS X $285 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />SAMPLING INSPECTION FEE _ $ 95/ HOUR <br />1T riser CVf c=ne cFFc Fnln WILL BE BILLED TO APPLICANT. <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $285 / FACILITY <br />INSTALLATION PLAN <br />(Plan Check and Const <br />TANK ID # <br />PLAN CHECK FEE = $760 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # s <br />$Z <br />TANK RETROFIT REPAIR FE _ $285 / F CILITY (use for monitoringequipment, spill buckets, tank sumps, misc.) <br />$ <br />PIPING REPAIR FEE = $285 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 95/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 95 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 95/ HOUR <br />1T riser CVf c=ne cFFc Fnln WILL BE BILLED TO APPLICANT. <br />ALL FEES ARE BASED ON I Ht: 4,a0 nVURLT RAID. umR­ u, <br />OFFICE U5E ONLY <br />SERVICE REQUEST # FACILITY IDAMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 07/28/06) <br />