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S SAN JOAQUIN COUNT ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd FACILITY NAME FACILITY CONTACT NAME ri' k'O' t 4 7 5 y 'ri I� II t`7 Gam/ f 1 iC�Cr�-r FACILITY ADDRESS SITE PHONE #�/WIITH AREA CODE I FZZ CITY STATE ZIP CODE # OF TANKS AT SITE ' ,� ., CA c} Z -- APPLICANT BILLING NAME APPLICANT CONTACT NAME CLOSURE FEE = $375 i TANK # TANKS X $375 = 2006 APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 0,, 5 . -2 CT l✓ �f �� CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # C' c} _e .5 Closure Installatio al Retrofit / . ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $375 i TANK # TANKS X $375 = 2006 2007 2008 2009 2010 2011 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) $ PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) $ SAMPLING INSPECTION FEE _ $ 1251 HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) $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 =$49.001 FACILITY PERMANENT CLOSURE (Removal or Permitted Closure in Place) TANK ID # (s): CLOSURE FEE = $375 i TANK # TANKS X $375 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $3751 FACILITY INSTALLATION PLAN CHECK (Plan Check and Construction Ins TANK ID # (s) : PLAN CHECK FEE = $1,000 / FACILITY REPAIR PLAN CHECK TANK ID # {s) TRANSFER FEE _ $ 25 TANK RETROFIT REPAIR FEE = $3751 FACILITY (use for monitoring equipment, cold starts, EVR upgrades, spill buckets, sumps, misc. $ PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) MISCELLANEOUS TRANSFER FEE _ $ 25 CONSULTATION FEE = $ 1251 HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR $ SAMPLING INSPECTION FEE _ $ 1251 HOUR ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE HILLED TO APPLICANT. TOTAL AMOUNT DUE I $ OFFICE USE ONLY SERVICE REQUES7# FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED EH 23 032 (REVISED 0671111 by KF)