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► SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL.lAFAI;fI-1 DEPARTMENT <br /> 304 East Weber Avenue,3`d Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(5"',floor):(209)468-3433 Web:www.sjr;ov.org/elid <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ACILI Y ADD SS SITE PHONE#WITH AREA CODE <br /> -3-CAC, 7 C/YL9 2r ec c- (do g <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE Ll <br /> iii CA ©1 '5 3(C & <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Cf <br /> APPLICANT MAILING ADDRESS' APPLICANT PHONE#WITH AREA CODE <br /> U)I'? F- f—vGl cry J-e'v�� � -G�t ��T- (Z(t 1�? <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> j ©(1 r Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 6 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 2002 2003 2004 2005 200 2007 <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=$285/TANK #TANKS X$285= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$285/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$760/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> TANK RETROFIT REPAIR FEE =$285/FACILITY (use for monitoring equipment,spill buckets,tank sumps,mise.) $ <br /> PIPING REPAIR FEE =$285/FACILITY (use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $95/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $95/HOUR $ <br /> SAMPLING INSPECTION FEE = $95/HOUR $ <br /> ALL FEES ARE BASED ON THE$95 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 01/29/07) <br />