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SAN JOAQUIN COUNTY <br /> _ ENVIRONMENTAL HEALTH DEPARTI 649 <br /> 600 East Main Stret,Stockton CA 95202-3029 <br /> Telephone.-(209)468-3420 Fax e(209)468 3433 Web:www sik <br /> ov or /a ehd <br /> FACILITY NAME <br /> FACILITY CONTACT NAME <br /> FACILITY ADDRESS <br /> SITE PHONE#WITH AREA CODE <br /> 3�W W Cat <br /> CITY STATE <br /> _- ZIP CODE #OF TANKS AT SITE ' <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> NM U.MMTEI <br /> APPLI��CA��NT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK i DONE CONTRACTDR ICC# <br /> Closure Installation Rea Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2005.2007) 2006 2007 2008 2009 2010 2011 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2011) <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 X49.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE $375/TANK #TANKS X$375= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins actions <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$375/FACILITY $ <br /> INS7ALLATON PLAN CHECK <br /> Plan Check and Constn lotion Ins ectlons <br /> TANK ID#(a), PLAN CHECK FEE_$1000/FACILITY is <br /> rff�RF <br /> N CHECK <br /> IT REPAIR FEE $375/FACILITY (usefor monitoring equipment,cold starts,EVR upgrades,— buckets sum s,mist.use for i in ,underdis enser containment,act.IR FEE_$375/FACILITY $ <br /> _. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> -- -- - CONSULTATION FEE $125/HOUR $. <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $125/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE $.125/HOURI' <br /> = .. <br /> .ALL FEES ARE BASED ON THE E125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE a1LLED TO APPLICANT. $ ' <br /> TOTAL AMOUNT DUE i <br /> OFFICE USE ONLY $ <br /> SERVICE REQUEST# FACILITY IO AMOUNT RECENED <br /> ' --" --------- CHECK# RECEIVED BY <br /> DATE RECEIVED <br /> EH 23 032(REVISED 08/1/17 by KF) <br />