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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 Jfeb:www.sj ov.or /ehd <br /> FACILITY NAME \ FACILITY CONTACT NAME <br /> ww <br /> j <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> C a1 <br /> CITY STATE �,` ZIP CODE #OETANKS TE <br /> DI <br /> ICA� "� <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLI ANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> e ` 1 Closure Installation R air Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2003-2008) 2004 2005 2006 2007 1 2008 2009 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009) <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 INA CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$315/TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$315/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s) <br /> PLAN CHECK FEE_$840/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> s ill buckets,sumps,mise. <br /> PIPING REPAIR FEE _$315/FACILITY (use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $ 105/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $105/HOUR $ <br /> SAMPLING INSPECTION FEE = $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# RE <br /> SR 71 BY DATE RECEIVED <br /> EH 23 032(REVISED 02123109) <br />