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• SAN JOAQUWCOUNTY <br /> ENVIRONMENTAL HEALTH DEPARTM11 <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sieov.ore/ehd <br /> FACILITY NAME FACILITY C TACT NAM <br /> FACILITY ADDRESS SITE PHOW9 WITH AREA CODE <br /> Q/v) <br /> ITr <br /> STA E ZIP CODE #OF TANKS AT SITE <br /> CA 95 <br /> AP ANTMADKh5S <br /> APP C T CONTACT NAME <br /> PLI ANT APP I P ON #WITH AREACITYg <br /> CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+7 TANK(2002-2007) 2002 2003 2004 2005 2006 2007 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008 8 New <br /> Installs as of 8/1/07) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> ZTANKSURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE - <br /> Removal or Permitted Closure in Place - <br /> _TANK.10# s CLOSURE FEE=$294/TANK #TANKS X$294= $ <br /> -TEMPORARYCLOSURE -- - - -- - - - - <br /> (PI n Review and Ins ecflons <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$294/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$784/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> J _ $ <br /> TANK RETROFIT REPAIR FEE =$29T/FACILITY use for monitodng equipment,spill buckets,tank sum s,misc. <br /> PIPING REPAIR FEE =$294/FACILITY (use for piping,under-dispenser containment,act) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $98/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR $ <br /> SAMPLING INSPECTION FEE _ $98/HOUR $ <br /> ALL FEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUc5T# FACILITY ID 1 AMOUNT I CHECK# I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 1]2!REVISED nRl]/nT <br />