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SAN JOAQUIN COUNN'N <br />ENVIRONNINTAL I IFALTI I DVIIARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 rax: (209) 468-3433 Web: LN,—ww. <br />FACILITY NAME <br />FACILITYCONTACTCONTACT NAME <br />A1✓� 1 0 <br />� <br />APPLICANT <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />(a <br />i--1("-z- <br />city <br />STATE <br />ZIP CODE 9 OF TANKS AT SITE <br />16 114 <br />cA1 <br />1 <br />APPLICANT BILLING NAME <br />1 <br />APPLICANT CONTACT NAME <br />� <br />APPLICANT <br />MAILING AD15RESS <br />/"? ; "� // "'t I - -- -- 61�t 1—,1,-7 1 <br />APPLICANT PHONE 9 WITH AREA CODE <br />/m/ <br />I ANK PFNAI. FY ASSESSED <br />$ <br />CITY <br />STATE ZIP CODE <br />CIRCLE WORK TO BE DONE j5 CONTRACTOR ICC # <br />Closure Installation Repair Refrofit <br />f ACTIVE FACILITY <br />20041 2005 2006 2007 2008 2009 <br />1 <br />5500 PCE INCLUDES FACILITY FEE + 1 TANK (2004-2007) <br />5550 FEE INCLUDES FACILITY FEE+ 1 TANK(2003.20 f0) — <br />$125 PER TANK AFTER FIRST TANK <br />CONSULTATION FEE $ 115/ HOUR <br />I ANK PFNAI. FY ASSESSED <br />$ <br />; TANK SURCHARGE = $15 1 TANK <br />LSTATE- SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY 1,14 A CUPA PROGRAM =S413.001 FACILITY <br />PERMANENT CLOSURE <br />1!Zqmoval or Permitted Closure in Place) --T <br />TANK 1D 4 (s) CLOSURE FEE = $345 1 TANK # TANKS X $345 - <br />TEMPORARY CLOSURE <br />{Pian Review and Insnertions) <br />I ANK 11) is (s) : TEMPORARY CLOSURE FEE; = $345 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction j ...... <br />TANK ID # (s): I PLAN CHECK FEE = $920 / FACILITY <br />CHECK <br />TANK RETROFIT REPAIR FEE = $3451 FACILITY (use for monitoring equipment, cold starts, EVR upgrades. <br />swill buckets, sumps, mise.} <br />PIPING REPAIR FEE =S345/FACILITY ,_ (use for pipm2® nder-dispenser containment. ectL <br />9 <br />MISCELLANEOUS <br />TRANSFER FEE $20 <br />CONSULTATION FEE $ 115/ HOUR <br />L,'L,'+L,-,tORIZEI)RELEASE EVALUATION _FEE =_1115/HOUR <br />$ <br />SAMPLING INSPECTION FEE = S 115/ HOUR <br />ALL t't:t;J AMC t5A3t:L1VN iNk x013NVVKLT KAI C. I IM: I MAI "L,=UZD t-AIU WILL Zt OfLLCU IV ArtLJUAN I. <br />OFFICE USE ONLY <br />