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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephaee. (209) 468-3420 Far., (209) 468-3433 Web: www sjcelRl.cam <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />-....._ LC <br />FACILITY A <br />SS <br />SITE # WITH AREA <br />15 C' <br />yy�� <br />v W-tC-lti1Ae �, <br />ncP�HONE (CODE <br />a 1 sq 1 " `-i t 1 <br />CITY <br />STATE <br />71P COD£ # OF TANKS AT SITE <br />t Po 1 cA <br />y <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />r ® Eh L:at1t: j Ci2UU{) t VIC <br />APPLICANT MAILING ADDRESS_ <br />g5r6 QJCAc. <br />APPLICANT PHONE # WITH AREA CODE <br />230--72cw <br />CITYSTATE ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />WS, nc 0(,u 0'a mw <br />yusure Installation Repair Retrofit , <br />$550 FEE INCLUDES FACILITY FEE . 1 TANK <br />$130 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE =$15/TANK <br />STATE SURCHARGE FOR FACILITIES NOT At <br />PERMANENT CLOSURE <br />�Rwnrwal or Pe died Closure in Place) <br />TANK ID # (s) <br />TEMPORARY CLOSURE <br />(Plan Review and Inspedions) <br />TANK ID # (s) : <br />INSTALLATION PLAN CHECK <br />(Plan Check and Conslru :I.n Inspections) <br />TANK ID # (a): <br />X $390 = <br />REPAIR PLAN CHECK <br />TANK RETROFIT REPAIR FEE = $390 / FACILITY (use for Dwnitoring equipment, cold starts, EVR upgrades, <br />spill buckets sumps mix.),r� '.. <br />PIPING REPAIR FEE = $3901 FACILITY _ (use fw I I antler-tlis sar cpntainmenL ect $1t1,! <br />MISCELLANEOUS <br />TRANSFER FEE = $ 25 $ <br />CONSULTATION FEE - $ 1301 HOUR _ <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 130 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 1301 HOUR <br />$ <br />FEES ARE RASED ON TME $130 HOURLY RATE. TN/E THAT E.E. FEES PWD WILL RE R.Lt . TO APPLICANT. <br />TOTAL AMOUNT DUE <br />$ (It t <br />C <br />OFFICE USE ONLY <br />! <br />G7 <br />SERVICE REQUEST FACILITY 10 COUNT RECEIVED I CNECK# RECEIVED BY <br />DATE RECEIVED <br />Pmt <br />EH 23 032 (REVISED 04-22-15) <br />I J. <br />1� <br />I <br />G <br />E <br />C <br />