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SAN JOAQUIN COUNTY <br /> 'P ENVIRONMENTAL HEALTH DEPARTMENT <br /> 868 E.Hazelton Ave.,Stockton,CA 95205-623 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjcehd.com <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Sa\Je- OVA `) � I` UO✓ 1 b-�'/� S1 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> �A7o w• Xi'TiQvwJQ Gyve _q3kA -- VW\ <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> C� CA �rj33a <br /> APPLICA BILLI G NAME APPLICANT CONTACT NAME <br /> APPLicAN'r MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK 2011 2012 2013 2014 2015 2016 <br /> $130 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.00/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$390/TANK #TANKS X$390= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$390/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE=$1040/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$390/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> $ <br /> PIPING REPAIR FEE=$3901 FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $1301 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $130/HOUR $ <br /> SAMPLING INSPECTION FEE _ $1301 HOUR $ <br /> FEES ARE BASED ON THE$130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITYID AMOUNTRECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 02-03-2016) <br />