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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTML <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 fci'eb: www.sigov.org/ehd <br />FACILITY NAME FACILITY CONTACT NAME <br />FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br />CITY STA E ZIP CODE # OF TANKS AT SITE <br />k CA/ <br />Aom it Anrr on 1 fur . <br />- — -- <br />APPLICANT AILING ADDRESS <br />ArrLIUAN I GUN I AG I NAME <br />APPLICANT PHONE # WITH AREA CODE <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />Installs as of 8/1/07) $125 PER TANK AFTER FIRST TANKTANK <br />2002 <br />AI <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />}C TCrj <br />f { <br />ci �j �lL, S <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s) : <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />Installs as of 8/1/07) $125 PER TANK AFTER FIRST TANKTANK <br />2002 <br />2003 <br />2004 <br />2005 <br />$ <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />ALL FEES ARE BASED ON THE S98 Hn11P1 Y RATE TIR= runt <br />$ <br />PENALTY ASSESSED <br />a006 <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.0 <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s) : <br />CLOSURE FEE = $294 / TANK <br /># TANKS X $294 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Ir <br />TANK ID # (s) : <br />PLAN CHECK FEE = $784 / FACILITY I $ <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />$ <br />PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 98/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />ALL FEES ARE BASED ON THE S98 Hn11P1 Y RATE TIR= runt <br />$ <br />DFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID T AMOUNT RECEIVED CHECK 4 RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 08131071 <br />