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SAN JOAQUIN COUNTY <br /> ENVIRONMEN'rAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Avc.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Pax.(209)468-3433 Web:www.sicelld.com <br /> FACILITY NAME FACILITY CONTACT NAME <br /> k Or Z (-L?- <br /> FACILITY AD ESS SITE PHONE 9 WITH AREA CODE <br /> CITY STATE ZIP CODE 1 9 OF TANKS AT SITE <br /> [YD( CA S <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> jtd(Z600061 69600 Inc- UINI(p z gLES <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE 9 WITH AREA CODE <br /> 4S-9.5 LUCAS rZtAtMj(d. 9 239~7208 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC 9 <br /> n.h J CA1 C-el I 'it—I-575---Closure inite$alion Regr Retrofit <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE•1 TANK 2010 2011 2012 2013 2014 2015 '. <br /> $130 PER TANK AFTER FIRST TANK <br /> TAW PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM X3300/FACILITY <br /> PEPIANENT CLOSURE <br /> Removol or Penni ted Closure in Piece <br /> TANK ID 9 a CLOSURE FEE=$390/TANK 9 TANKS X 380= { <br /> TEMPORARY CLOSURE - <br /> Plan Review and 1 ons <br /> TANK 1D 9(s): TEMPORARY CLOSURE FEE= 390/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> (Pian Check and Construmfion Inspections) _ <br /> TANK ID 9(s): I PLAN CHECK FEE=$1040/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID 9(a): 2 and 3 j <br /> TANK RETROFIT REPAIR FEE_$390/FACILITY(use for monitoring equipment,cold starts,EVR upgrades, k3a. j <br /> PIPING REPAIR FEE_$390/FACILITY use for piping,urMer-dis eraser contalnmenOct. $TCIJ <br /> MISCELLANEOUS <br /> _TRANSFER FEE _$25 <br /> UNAUTHORIZED RELEASE EVALUATION FEE _$1301 HOUR <br /> SAMPLING INSPECTION FEE e$1301 HOUR <br /> FEES ARE BASED ON THE$130 HOURLY RATE.TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. ^y <br /> TOTAL AMOUNT DUE $ l[7a <br /> OFFICE USE ONLY a. <br /> SERVICEREOUESTa I FACILITY ID AMOUNT RECEIVED I CHECKS I RECEIVED 0) DATE RECEIVED C7 <br /> EH23032(REVISED$4.22.15) ) <br />