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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: nny.Sieov.ore/ehd FACILITY NAME FACILITY CONTACT NAME C CV rc>, FACILITY ADDRESS SITE PHONE # WITH AREA CODE IDF 1_ CITY ATE ZIP CODE # OF TANKS AT SITE S j CA SZ APPLICANT BILLING NAME APPLICANT CONTACT NAME TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $375 FACILITY APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE lqc 2007 CITY '�„ STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # r— Closure Installation Repair Retro i ; 72-7 PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $375 / TANK # TANKS X $375 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $375 FACILITY $ $500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) $125 PER TANK AFTER FIRST TANK 2006 2007 2008 2009 2010 2011 $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $15 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY $ PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $375 / TANK # TANKS X $375 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $375 FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID # (s) : PLAN CHECK FEE = $1,000 / FACILITY $ REPAIR PLAN CHECK TANK ID # (s) TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, spill buckets sumps, misc.) $ 27r2:1 - PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. $ MISCELLANEOUS TRANSFER FEE _ $ 25 $ CONSULTATION FEE _ $ 125/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR $ SAMPLING INSPECTION FEE = $ 125/ HOUR ALL FEES ARE BASED ON THE 5125 Hnuw1 V RATE $ TOTAL AMOUNT DUE $ OFFICE USE ONLY SERVICE REQUEST # I FACILITY ID I AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED EH 23 032 (REVISED 0811111 by KF)