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SAN JOAQUIN COUNTY 9 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orrg/ehd ' <br /> FACILITY NAME FACILITY CONTACT NAME <br /> f 1-o 5 ( (o 0 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> (s 2 3•'7 N- 7harfa N �c� <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> /fid�' CA 1352Yd v� <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Got a ries C 77,GrQ S Ce,- . 7Z 11 o 2u rz <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> )370 5. 41rn A-- tj-v< 213 3os-G / 60 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> d rGVL� -- G10 � <br /> 7rClosure Installation Repai Retro A'SZy- <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) 2003 2004 2005 2006 2007 2008 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) <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=$294/TANK #TANKS X$294= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$294/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$784/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE - 294 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc.)7 <br /> PIPING REPAIR FEE _$294/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $98/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $98/HOUR <br /> SAMPLING INSPECTION FEE _ $98/HOUR <br /> ALL FEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUESTS FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 12/31/07) <br />