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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. Hazelton Ave., Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sggov.or /g ehd FACILITY NAME FACILITY CONTACT NAME ? /r `-6/t4 (!F ��.J 2008 FACILITY ADDRESS SITE PHONE # WITH AREA C DE A -ONE GAS &FOOD' b s-3 r-� % CITY STATE ZIP CODE # OF TANKS AT SITE CA PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. APPLICANT BILLING NAME APPLICANT CONTACT NAME TANK ID # (s): APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2008 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # 2012 Closure Installation Repair Retrofit ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $375 / TANK 2008 2009 2010 2011 2012 2013 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR $ SAMPLING INSPECTION FEE = $ 125/ HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED TANK SURCHARGE = $15 / TANK Is STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ 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) : I PLAN CHECK FEE = $1000 / FACILITY REPAIR PLAN CHECK TANK ID # (s) : $ TRANSFER FEE _ $ 25 TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, spill buckets, sumps, misc.) CONSULTATION FEE = $ 125/ HOUR $37 PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR 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 $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. TOTAL AMOUNT DUE $ 7 OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED EH 23 032 (REVISED 1/16/2013 by KF)