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{:; � .mti�:},A ! • N+AN NN Nl VAN <br />V-1 <br />! SAN R?AQUIN COUNTY ! <br />ENVIRONMENTAL HEALTH DEPARTMENT ' CAJ <br />600 East Main Street, Stockton, CA 95202-3029 ! + <br />y , ! Telephone: (209) 468-3420 fax..(2q9) 468-3433 Web: ww�•siov <br />FACILITY NAME FACILITY CONTACT NAMs <br />i CILITY ADD ESS <br />N ��) SITE PH NE #WITH AREA CODE _ <br />CITY STATE Y QDE # OF TANKS AT SITE ! <br />APPLICANT BILLIN�Gi �N,A�ME APPLICANT C,QNTACT <br />Nm ko"�Tf,. <br />APPLICANT MAILING AbDRESS APPLICANT PHONE # WITH AREA CODE <br />CITY <br />STATE. YIP CODE <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) 2006 2007 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011). <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 —UF <br />PERMANENT CLOSURE <br />TANK ID #(s) : <br />TEMPORARY I CLOSURE FEE $075 / TANK <br />CLOSURE <br />(Plan Review and Inspections) <br />009 2010 2011 <br />a <br />TANKS X $3715 = <br />TANK ID # (s) :TEMPORARY CLOSURE FEE _ $375 /FACILITY <br />$ <br />INSTALLATION PLAN CHECK <br />Pian Check and Construction Ins ections <br />TANK ID # (s) : <br />$ <br />PLAN CHECK FEE _ $1,000 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) <br />TANK RETROFIT REPAIR FEE _ $375 / FACILITY (use for monitoring equipment, <br />cold starts, EVR upgrades, <br />PIPING REPAIR FEE $375 /FACILITY use'for piping, under -dispenser containment, ect, <br />_.. <br />_ <br />MISCELLANEOUS <br />TRANSFER FEE <br />CON$ULTAi i©N FEE = $125f HOUR- - <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 125 O <br />/HUR <br />_ <br />_G"'1 _SPECf1_O_N, FEE _ $ 125/HOUR <br />ALL FEEARBASEDD ON THE $125 HOURLY <br />$ <br />.-..- <br />RATE;"TIME"PHAT EXCEEDS FEES PAID VVQ.L BE BILLED TO APPLICANT. <br />TOTAL.AMouNT DUE <br />OFFICE U3E ONLY .:. _ . . . <br />$ <br />