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SAN JOAQUIN COUNTY It <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.orp,/ehd <br /> nFACILITY <br /> NAME �{ FACILITY CONTACT NAME <br /> L-VA <br /> ADDRESS T PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE <br /> _ #OF TANKS AT SITE <br /> TQC 1J CA <br /> APPLICANT,—A-NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> C�`CC: -�tj�] 9 .f�� Closure Insdallatio Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2003-2008) 2004 2005 2006 2007 2008 2009 <br /> 5.550 FEE INCLUDES FACILITY FEE+ 1 TANK <br /> $125 PER TANK AFTER FIRST TANK ,$ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00!FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$3151 TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ect#ons <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$315/FACILITY is <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK iD#(s): PLAN CHECK FEE=$840/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK lD#(s): <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts, EVR upgrades, $ <br /> s iW tauckets,sum s,misc. <br /> PIPING REPAIR FEE _$315/FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOU5 <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $1051 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1051 HOUR $ <br /> SAMPLING INSPECTION FEE = $ 1051 HOUR $ <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> MSR <br /> EH 23 032{REVISED 02123109) <br />