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soSAN JOAQUIN COUNTY go ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgoy.orgx/ehd FACILITY NAME FACILITY CONTACT NAME Q0I1L S"p VM I O W A-� U%A1-'�0 �( FACILITY ADDRESS SITE PHONE # WITH AREA CODE 106 w- Lou(st- Avg. - 116 33r3 -itsz CITY STATE ZIP CODE # OF TANKS AT SITE VLA A -k( t -t- c 4 ICA 9 x 3 3 6 Z APPLICANT BILLING NAME APPLICANT CONTACT NAME IN A L T o -r -k � C. t, KLt 4� :3:A' C, VM I O W A-� U%A1-'�0 �( APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE P.0• Bo)( (ozr 116 33r3 -itsz CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # Vv - S a-C1r'a C A c? s6 a ( Closure Installation Repair trof At:11VE rAGILIrY _.. TANK ID # (s): $500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) $125 PER TANK AFTER FIRST TANK 2003 2004 2005 12006 2007 2008 $ $ 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 = $294 / TANK # TANKS X $294 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $294 / FACILITY .REPAIR PLAN CHECK TANK ID # (s) : $ TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, d starts, E upgrades, Z / '( spill buckets, sumps, misc. $ PIPING REPAIR FEE = $294 / FACILITY use for piping, under -dispenser containment, ect. $ MISCELLANEOUS TRANSFER FEE _ $ 20 $ CONSULTATION FEE _ $ 98/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR $ SAMPLING INSPECTION FEE _ $ 98/ HOUR Al 1 CCCC ADC DACCA Au — !ne u $ .. w j HWo "wUK& r F%m 1 C. 1 WE I HA I EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SIR EH 23 032 (REVISED 12/31/07)