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• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMA <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax. (209)468-3433 Web: v <br /> )yWw.sW .or /ehd <br /> ,o g_ <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 1164d kA &)C&uh� W-'e, <br /> FACILITY ADDRESS SITE PHONE#WITH AR EX CODE <br /> �qqo �- ocLA (Am ) q61 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> I CA qScP/,5- J3.a� I I <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ?b7- te'k-'miel, 1-40�1-00 qIdLmnW vUilv �A' t MUM <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Ct iClosure lnstallation(!a�5, Retrofit � S7 90 7 - UT <br /> ACTIVE FACILITY <br /> 2003 2004 2005 2006 2007 2008 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) — <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=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$294/TANK #TANKS X$294= $ <br /> TEMPORARY CLOSURE <br /> (131an Review and lnse2ctions) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE $294 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction lnsp2ctions) <br /> TANK ID#(s): PLAN CHECK FEE $784 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets,sumps,misc.) <br /> PIPING REPAIR FEE $294/FACILITY (use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE $20 $ <br /> CONSULTATION FEE = $98/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR $ <br /> SAMPLING INSPECTION FEE = $98/HOUR $ <br /> ALL FEES ARE BASED ON THE$98 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 /> SIR <br /> EH 23 032(REVISED 12131107) <br />