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- SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPAR-n <br /> 600 East Main Street,Stockton,CA 95202 3029 <br /> Telephone.(209)468-3420 Fax:(209)468-3433 Web.www.sj ov�.org/ehd <br /> FACILITY NAME I FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> &Y'? rn ; S7 - (/t//45 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> ICA �1 S33d <br /> APPLICANT BILLING NAME I APPLICANT CONTACT NAME <br /> cl&l c oy r e <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> bV- 09 33'I <br /> CITY STATE UP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> gstS Closure Installation(Ke Retrofit <br /> ACTIVE FACILITY <br /> 2006 2007 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) 2002 2003 2004 2005 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008 8 New <br /> Instalis.as of 8/1/07) $ <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=$24.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place - <br /> TANK ID#(a): CLOSURE FEE=$294/TANK #TANKS X$294= $ <br /> TEMPORARY CLOSURE <br /> Review and Ins 'ons <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$294/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <br /> TANK ID#(s): PLAN CHECK FEE=$784/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): n p <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY use for monitoringequipment,s ill buckets,tank sumps,misc. $Of <br /> PIPING REPAIR FEE =$294/FACILITY $ <br /> (kue forpiping,under-dispenser containment eeL <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $98/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $981 HOUR $ <br /> SAMPLING INSPECTION FEE _ $98/HOUR $ <br /> ALL FEES ARE BASED ON THE$88 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REDDEST# FACILrfY ID AMOUNT RECENED CHECK RECEWED BY DATE RECEIVED <br /> SR <br /> EH 9 032 fREVISED 09/31071 <br />