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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENTS, <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com <br />FACILITY NAME <br />APPLICANT <br />FACILITY CONTACT NAME <br />-?CCCtCLL ('(XC (Aj <br />j- Gh'tV-VA` GZS�r c <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />LA4I 5 ?a -C t �) (- A -v` -1,1 LAS <br />zv- 4 � 7- <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE Ll <br />k -v Ck - Y-\ <br />I CA <br />,-2- <br />q Gj z o' -2 - <br />APPLICANT BILLING NAME <br />C t' Yl � cn-( Int- +ro <br />APPLICANT CONTACT NAME <br />K(kj Fi e e n He V[ La CJ <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />It % b u' y �� r \ 1 a c� S -f re P -F <br />CITY STATE ZIP CODE <br />cz S '� � <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />G� V1 C ► 5 <br />Closure Installatio Re ai Retrofit <br />ACTIVE FACILITY <br />TANK ID #s <br />CLOSURE FEE = $375 / TANK <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />2012 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) <br />PIPING REPAIR FEE = $375 / FACILITY use for i in , under-dis enser containment, ect. <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />SAMPLING INSPECTION FEE _ $ 125/ HOUR <br />CQ OA"n Wil I aF au 1 Fn To APPI ICANT- <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$ <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 =$49.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID #s <br />CLOSURE FEE = $375 / TANK <br /># TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />Check and <br />TANK ID # (s) : I PLAN CHECK FEE = $1000 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) <br />TRANSFER FEE _ $ 25 <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />Will buckets, sumps, misc. <br />CONSULTATION FEE _ $ 125/ HOUR <br />PIPING REPAIR FEE = $375 / FACILITY use for i in , under-dis enser containment, ect. <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE _ $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />SAMPLING INSPECTION FEE _ $ 125/ HOUR <br />CQ OA"n Wil I aF au 1 Fn To APPI ICANT- <br />ALL FEES ARE BASED ON I tit $125 HOURLY RA i o. nmo i nA i ��� �� + " - - •-•-- -- - ---- - - <br />TOTAL AMOUNT DUE `r <br />Vt MCE USE %Jl-4LT <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY I DATE RECEIVED <br />EH 23 032 (REVISED 04113/12 by KF) <br />