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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTHDEPARTMENT*'W <br /> 304 East Weber Avenue,3d Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(P lour):(209)468-3433 Web:wvvW.sieov ore/ehd <br /> FACILjNAME FACILITY CONTACT NAME <br /> I - <br /> FACILSITE PHONE#WITH AREA CODE(ol— <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> 1 L� CA 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Se(V:l.e, <br /> APPLICANT MAILING ADDRESS I APPLICANT PHONE#WITH AREA CODE <br /> 09 -2 - ) 3 <br /> CITY STATE LP CODE CIRCLE WORK TO ONE CONTRACTOR ICC f <br /> Closure Installation epai Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 2000 2001 2002 2003 2004 2005 <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <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# s - CLOSURE FEE_$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,spill buckets,tank sumps,misc.)$�'S <br /> $ <br /> PIPING REPAIR FEE _$279/FACILITY use for'piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $93/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR <br /> SAMPLING INSPECTION FEE _ $93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02122/06) <br />