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SAN JOAQUIN COUNTY <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.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />C.V rC)n <br />",, e ( <br />FACILITY ADDRESS <br />—SWE PHONE # WITH AREA CODE <br />2009 <br />2 L,, <br />CITY I VATE <br />I ZIP CODE <br /># OF TANKS AT SITE <br />Ali CA <br />Closure Installation Repair Retro i �: 7 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />G 1^Lc c-,/ J <br />Z <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2009 <br />2010 <br />CITY <br />STATE <br />ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />Closure Installation Repair Retro i �: 7 <br />AG I IV C I-Allu I Y __ <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) <br />TEMPORARY CLOSURE FEE= $375 FACILITY <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br /># TANKS X $375 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, eat. <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE= $375 FACILITY <br />3TALLATION PLAN CHECK <br />an Check and Construction Ir <br />TANK ID # <br />CHECK FEE = $1,000 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, misc. <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, eat. <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 125/ HOUR <br />1111 =- An <br />$ <br />ono�U ON I no .512.7 HOURL] RAI E. TIME THAT I EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE $ <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 0811111 by KF) <br />