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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.sjgov,org,/ehd <br />FACILITY NAME FACILITY CONTACT NAME <br />FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br />CITY STATE I ZIP CODE # OF TANKS AT SITE <br />CA <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />TANK ID # (s): <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />2005 <br />CITY STATE <br />ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />2009 <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE= $366 / TANK <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2005-2007) <br />PIPING REPAIR FEE = $366 / FACILITY use for piping, under -dispenser containment, ect. <br />SAMPLING INSPECTION FEE = $ 122/ HOUR <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 />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE= $366 / TANK <br />T# TANKS X $366 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $366 / FACILITY <br />kLLATION PLAN CHECK <br />Check and Construction Ir <br />TANK ID # <br />PLAN CHECK FEE = $976 / FACILITY <br />REPAIR PLAN CHECK <br />AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />TANK ID # (s) : <br />TRANSFER FEE _ $ 25 <br />TANK RETROFIT REPAIR FEE = $366 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, misc. <br />PIPING REPAIR FEE = $366 / FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <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 EXGEEUS ttt5 FAiu vviLL BE BiLLED TO AFFUG N i. <br />OFFICE I ISE ONLY <br />SERVICE REQUEST # FACILITY ID <br />AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 07121/10) <br />2 `It -732, <br />