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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT RECENED <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjcehd.co EAS' i 1 2017 <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />(As of 8/1/16) $583 FACILITY FEE + $139 PER TANK <br />2011 <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />2014 <br />2015 <br />CITY <br />STATE <br />ZIP CODE # OF TANKS AT SITE <br />CIRCLE WORK TO BE DONE <br />CA <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />(As of 8/1/16) $583 FACILITY FEE + $139 PER TANK <br />2011 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2014 <br />2015 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />(As of 8/1/16) $583 FACILITY FEE + $139 PER TANK <br />2011 <br />2012 <br />2013 <br />2014 <br />2015 <br />2016 <br />Facility Fee NO LONGER INCLUDES FIRST TANK <br />PIPING REPAIR FEE= $417 / FACILITY use for piping, under -dispenser containment, ect. <br />(2011 -Aug 1, 2016) $550 FEE INCLUDES FACILITY FEE + 1 TANK. <br />$ ^� <br />$130 PER TANK AFTER FI TANK <br />TANK PENALTY ASSESSED <br />-4 <br />TANK SURCHARGE = $15 / TANK <br />$ <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $417 / TANK <br /># TANKS X $417 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $417 / FACILITY <br />119 ro <br />INSTALLATION PLAN CHECK <br />CHECK # <br />Plan Check and Construction Inspections) <br />DATE RECEIVED <br />'?;4-D6-0 -- <br />I <br />$ <br />TANK ID # (s) : <br />PLAN CHECK FEE = $1112 / FACILITY <br />REPAIR PLAN CHECK <br />CHECK # <br />TANK ID # (s) : <br />DATE RECEIVED <br />'?;4-D6-0 -- <br />6-06*.� 111J l <br />TANK RETROFIT REPAIR FEE = $417 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />5/111/2 <br />spill buckets, sumps, misc. <br />PIPING REPAIR FEE= $417 / FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />CONSULTATION FEE _ $ 139/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 139 / HOUR <br />201? <br />SAMPLING INSPECTION FEE _ $ 139/ HOUR I $ �rrMEb <br />FEES ARE BASED ON THE $139 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE $ <br />OFFICE USE ONLY , <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED <br />CHECK # <br />RECEIVED BY <br />DATE RECEIVED <br />'?;4-D6-0 -- <br />6-06*.� 111J l <br />t4?> <br />5/111/2 <br />EH 23 032 (REVISED 07-15-2016) / ul /J ! �� q3a <br />