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SAN JOAQUIN COUNTY ENVIR0NM3 NTAL HEALTH DEPARTMEl 600 East Main Street,Stockton,CA 95202-30 Telephone:(209)468-3420 Fax:(209)458-3433 Web:www.sigov.orglehd FACILITY NAME FACILITY CONTACT NAME L4�) J34(�o1/0 cau -CDR-AoA4+3,J YZ 1. 014rJ M C.0—i�jN FACILITY ADDRESS SITE PHONE#WITH AREA CODE CITY STATE ZIP CODE #OF TANKS AT SITE 5 CA q rS zb APPLICANT BILLING NAME APPLICANT CONTACT NAME Si�a, tJ 13L4 C uj D AK S�F Rvl ►,j �S t7* APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE P.&. g a m L-,ZD '3 6 Z --q-9"b0 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# Closure Installation epai� Retrofit 1"' 7 q ACTIVE FACILITY 2004 2005 2006 2QQ7 2f}O8 Z4t]9 $500 FEE INCLUDES FACILITY FEE+1 TANK(2004-2007) $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2008-2009) $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED TANK SURCHARGE=$151 TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.001 FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID# s CLOSURE FEE=$3151 TANK #TANKS X$315= TEMPORARY CLOSURE Plan Review and Ins ections TANK ID#(s): TEMPORARY CLOSURE FEE_$3151 FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Ins ect4ons TANK ID#(s): PLAN CHECK FEE_$840 1 FACILITY REPAIR PLAN CHECK TANK ID#(s): TANK RETROFIT REPAIR FEE =$3151 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ i spill buckets,runt s,mist. PIPING REPAIR FEE _$315 1 FACILITY (use for piping,under-dispenser containment,eat. MISCELLANEOUS $ TRANSFER FEE _ $20 CONSULTATION FEE = $1051 HOUR UNAUTHORIZED RELEASE EVALUATION FEE _ $1051 HOUR SAMPLING INSPECTION FEE _ $1051 HOUR ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL.BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# FACILITY I❑ AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED SR FH 23 032 IRITIIISED 031201D9)