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SAN JOAQUIIN COUNTY <br /> ENVIRONMEN'T'AL HEALTH DEPARTMENT <br /> 1868 E.'Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.oru/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> X11'1 ' 1) cc <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA M6 2 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> G1 ;� <br /> APPLICAN MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE ORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2008 2009 2010 2011 2012 2013 <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=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.001 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in PlaceII �] <br /> TANK ID# s <br /> ' �7�i CLOSURE FEE=$3751 TANK #TANKS X$375= 1 L <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$375/FACILITY is <br /> INSTALLATION PLAN CHECK <br /> Pian Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$10001 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK 10#(s): <br /> TANK RETROFIT REPAIR FEE =$375 1 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE _$3751 FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEF = $25 $ <br /> CONSULTATION FEE = $1251 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1251 HOUR $ <br /> SAMPLING INSPECTION FEE = $125!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 /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 1/16/2613 by KF) <br />