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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjo,—ov.org/ehd <br /> FACILITY NAME I FACILITY CONTACT NAME <br /> t 61 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAm5g I APPLICANT CONTACT NAME <br /> / , ; <br /> APPL AN MAILING ADDRESS I APPLICANT PHONE# H AREA CODE <br /> AN <br /> CITY ST TE ZIP CODE -CIRCLE WORK TO BE DONE CONTRACTOR ICC#- <br /> Z5Closure Installation Repair Retrofit <br /> rACTnIVEFACILITY <br /> 2003 2004 2005 2006 2007 2008 <br /> INCLUDES FACILITY FEE+1 TANK(2002-2007)INCLUDES FACILITY FEE+1 TANK(2008) <br /> R TANK AFTER FIRST TANK $ <br /> NALTYASSESSEDRCHARGE=$15/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=$315/TANK #TANKS X$315= $ <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$315/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Constmction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$8401 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, h <br /> spill buckets,sumps,mist.) <br /> PIPING REPAIR FEE =$315/FACILITY ^f <br /> (use for piping,under-disenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $105/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $105/HOUR $ <br /> SAMPLING INSPECTION FEE _ $105/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# I FACILITY ID I AMOUNT RECEIVED CHECK# - RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 7/18/08) <br />