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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone.(209)468-3420 Fax(209)468-3433 Web:www.sieov.or <br /> FACILITY NAME FACILITY CONTACT NAME <br /> r' o <br /> FACILITY ADDRESS SITE PH NE#WITH AREA CODE <br /> rW C - /wo <br /> CITY I STATE LP CODE TO—OF TANKS AT SITE <br /> CA <br /> APPI,ICANT BILLING NAME APPLICANT CONTACT NAME <br /> rvy In G ��� <br /> APPLICANT AILING DRESS APPLICANT PWOOgNE ynW <br /> V�' -IT�H�A�R�EA CODE <br /> �U /`� <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installatio Repair R tro8t <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2005-2007) 2005 2006 2007 2008 2009 2010 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2010) <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=$49.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s : CLOSURE FEE=$366/TANK #TANKS X$366= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE_$366/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$976/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$366/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, C <br /> spill buckets,sumps,mist.) „n <br /> PIPING REPAIR FEE _$366/FACILITY use for piping,under-dispenser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $122/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $122/HOUR $ <br /> SAMPLING INSPECTION FEE = $122/HOUR $ <br /> ALL FEES ARE BASED ON THE$122 HOURLY RATE TIME THAT EXCEEDS FEES PAID INILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED I CHECKS I RECEIVED BY I DATE RECEM <br /> SR <br /> EH 23 032(REVISED 07/21/10) <br />