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09/26/2008 PRI 16:48 FAX 2094683433 SJC HHD 0006/007 <br /> Rol <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone.*(209)468-3420 Pax:(209)468-3433 Web.WWW.sjgov.org/ehd <br /> FACILITY E A ILITY CONTAC E <br /> FACIENYA013RESS SITE PHONE#WITH AREA CODE <br /> =CkTy STATE ZIP CO E #09 TANKS AT SITE <br /> CA S <br /> APPLICANTSILL100AME APPLICANT CONTACT NAME <br /> A PLICANT MAILING ADDRESS APPLICANT PHONE It WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO HE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY _ <br /> $500 FEE INCLUDES FACILITY FEE*1 TANK(2002-2007) 2003 2004 2005 2006 2107 1 2008 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> iANKSURCHARGE=S15/TANK <br /> STATE SURCHARGE FOR FACILITIES t40T ALREADY ON INVENTORY IN A COPA PROGRAM=$24.001 FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permilued Closure in Place <br /> TANK ID#(a): CLOSURE FEE_$294!TANK #TANKS X$294= <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ions <br /> TANK 10#(s): TEMPORARY CLOSURE FEE_$294/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$7841 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for nwnaoring equipment,cold starts.EVR upgrades, $ <br /> al buckets.sum s,misc. <br /> PIPING REPAIR FEE _$294/FACILITY use for piping,under-dispenser containment ed.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FFA _ $981 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $98/HOUR <br /> SAMPLING INSPECTION FEE = $98/HOUR <br /> ALL FEES ARE BASED ON THE SSB HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REDUESTp FACILITY ID 1 AMOUNT RECEIVED I CHECK It I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032)REVISED 12/31N7) <br />