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c <br /> 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 ov.or />?ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> - �A 5 d ' Lk <br /> FACILITY ADDRESS SITE PHO E#WITH AREA CODE <br /> db <br /> CITYSTATE ZIP CODE #OF TANKS AT SliE�l <br /> `S <br /> va CA 7 <br /> APPLICANT BILLING NAME APP NT CONTACT NA <br /> lame, <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY ( STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Instaflatio epair trofit <br /> ACTIVE FACILITY <br /> 6 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2005-2007) 2005 200 2007 2008 2009 2010- <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2010) - <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=$366/TANK #TANKS X$366= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$366/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> _--- -TANK -ID : -- — ---_-- -- --- PLAN CHECFCFEE=$976/FACILITY $ --- <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$366/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE _$366/FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $122/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $122/HOUR $ <br /> SAMPLING INSPECTION FEE _ $122/HOUR $ <br /> ALL FEES ARE BASED ON THE$122 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 07/21/10) <br />