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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj og v.or /g ghd FACJLITY NAME FA ITY CONTACT NAME CLOSURE FEE = $315 / TANK R APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE FACILITY D ESS SITE PHONE # WITH AREA CODE CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # on CITY STATE ZIP C,9DE # OF TANKS AT SITE CA t 'S a $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) $125 PER TANK AFTER FIRST TANK APPLICANT BILLING NAME AEeLICANT CONTACT NAME CLOSURE FEE = $315 / TANK �^ APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2006 2007 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # on $ PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) 1111730(hosure Installation Repai Retrofit ' i ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $315 / TANK 2003 2004 2005 2006 2007 2008 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) $ PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) SAMPLING INSPECTION FEE _ $ 105/ HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $15 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $315 / TANK # TANKS X $315 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $315 / FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID # (s) : I PLAN CHECK FEE = $840 / FACILITY REPAIR PLAN CHECK TANK ID # (s) : TRANSFER FEE _ $ 20 TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, spill buckets, sumps, misc. $ PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) MISCELLANEOUS TRANSFER FEE _ $ 20 CONSULTATION FEE _ $ 105/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR SAMPLING INSPECTION FEE _ $ 105/ HOUR ALL FEES ARE BASED ON THE $105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 7/18/08)