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Y <br /> SAN JOAQUIN C OUN'1 Y <br /> EN'\'IRONN'll:NTAI. il_:\L'1'll DE_PART;\91{NT <br /> 600 East I\ialn Succl, Stockton, CA 95202-302() <br /> Telephone: (209)-JOS-3420 Pax: (209)468-3431 Web: wNN �� Nj,,)\ chd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA COUP <br /> 3 CIO <br /> CITY _ If STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANTNAME APPLICANT CONTACT NAME , <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA <br /> C, r STATE ZIP CODE CIRCLF WORK TO BE DONE CONTRACTOR ICC # <br /> �< Clos e Inslallat lrl= Repair Relrofit <br /> ACTIVE FACILITY <br /> 2003 <br /> i 5500 FEE INCLUDES FACILITY FEE - 1 TANK(2002.2007) 2004 2005 2006 2007 2008 <br /> S550 FEE INCLUDES FACILITY FEE + 1 TANK <br /> 5125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED I $ <br /> TANK SURCHARGE =S15 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24 00/FACILITY <br /> PERMANENT.CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s) CLOSURE FEE =S315/TANK #TANKS X 5315 = S <br /> TEMPORARYCLOSURE -- <br /> (Plan Review and Inspections) <br /> TANK ID# s) $ <br /> ( TEMPORARY CLOSURE FEE _ $315/ FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction nsoecuons <br /> TANK ID;;(s) PLAN CHECK FEE =$840/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETRGF;T REP:,F: Ei = 5315!FACILITY (use for monitoring equipment cold starts EVR upgrades, <br /> s ill ouckets,sumps,mist <br /> PIPING REPAIR FEE _ $315/ FACILITY (use for piping,under-dispenser containment,ect) l <br /> MISCELLANEOUS <br /> TRANSFER FEE = S20 $ <br /> CONSULTATION FEE = S 105 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $ 105/HOUR $ <br /> SAMPLING INSPECTION FEE = S 105/HOUR $ <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR j <br /> EH 23 032(REVISED 7/18/08) <br />