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SAN YbAQUIN COUNTY <br />ENiTIRONMENTAL HEALTH DEPARTMENT <br />304 Eaet Weber Avenue, 3b Floor, Stockton, CA 95202-2708 <br />TelcpTiome. (209) 468-3420 Fax (S°2,floot)r (209) 4683433 Web: www.sjgov.orsiebd <br />FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br />S; C U A <br />CITY STATE 23P CODE # OP TANKS AT SITE <br />e L,` CA <br />LA - <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />irvi S S <br />APPLICANT MAILING ADDRESS APPLICANT aHONi: # WITH AREA CODE <br />QLL i <br />CITY STATE I ZIP CODE CIRCLE: WORM TO BE DONE CONTRACTOR ICC # <br />5 0 , Closure lnstsltation ii' Retrofit c 4:(— <br />ACTIVE <br />f <br />ACTIVE FACILITY <br />TANK ED# s I <br />2000 200 <br />2002 <br />2003 <br />2004 2005 <br />$500 FEE INCLUDES FACILITY FEE * 7 TANK <br />CONSULTATION FEE = $ 93/ HOUR <br />$ <br />PIPING REPAIR FEE 791 FACILITY two for piping, under -dam ensar containment, ect. <br />$ <br />UNAUTHORIZED RELEASE* EVALUATION FEE =:S!93/HOUR <br />$125 PER TANK AFTER FIRST TANK <br />SAMPLING INSPECTION FEE; = $ 931 HOUR <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE - $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM ®$24.001 FACILITY <br />.r <br />REPAIR PLAN CHECK <br />TANK ED# s I <br />TRANSFER FEH = $ 20 <br />TANK RETROFIT REPAIR FEE a $2791 FACILITY use for monitoring a ui ment, spill buckets, tank sumps, miso.) <br />CONSULTATION FEE = $ 93/ HOUR <br />$ <br />PIPING REPAIR FEE 791 FACILITY two for piping, under -dam ensar containment, ect. <br />$ <br />MISCELLANEOUS <br />TRANSFER FEH = $ 20 <br />CONSULTATION FEE = $ 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE* EVALUATION FEE =:S!93/HOUR <br />SAMPLING INSPECTION FEE; = $ 931 HOUR <br />1%66 rMUiPAKP oiaxv vi®1 RG.Pa "W -i, ,�..,..a=..,.... cnv�w... ��....®...�..—---.—.... e.�. _... <br />