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1 <br />SAN JOAQUIN COUNTY <br />ENvtRQNmENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 �+ <br />Telephone: (209) 468-3420 Fa (209) 468-3433 Web: wNvw.sjRov.orgfehd <br />FACILITY NAME FACILITY CONTACT NAME <br />FACILITY ADDRESS SITE PHONE WITH AREA CODE <br />CITY LCA <br />TE ZIP CODE # OF TANKS AT SITE <br />S <br />APPLICANT BILLING NAME I APPLICANT CONTACT NAME <br />APPLICANT MAILING ApDRESS APPLICANT PHONE #WITH <br />CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />Closure Installation r4pay Retrofit <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE+ 1 TANK (2007-2008) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $151 TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK 1D # (s) : <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />2008 1 2009 12010 12011 12012 1 2013 <br />IN A CUPA PROGRAM <br />CLOSURE FEE = $3751 TANK I # TANKS X <br />TEMPORARY CLOSURE FEE= $375 1 FACILITY <br />TANK ID # (s) : I PLAN CHECK FEE = $1 DDD 1 FACILITY <br />REPAIR PLAN CHECK <br />TANK ID#(s). <br />TANK RETROFIT REPAIR FEE = $3755 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, mist.) <br />LITY <br />$ <br />W <br />$ <br />PIPING REPAIR FEE _ $375 1 FACILITY (use for piping,under-dispenser containment, ect.) $ <br />MISCELLANEOUS <br />TRANSFER FEE = $ 25 $ <br />CONSULTATION FEE _ $ 1251 HOUR $ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 1251 HOUR $ <br />SAMPLING INSPECTION FEE = $ 1251 HOUR $ <br />ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE <br />