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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.sigov.org—/ehd FACILITY NAME TANK ID # (s): FACILITY CONTACT NAME �BEfthy� *06 ,'�L r I1L FACILITY ADDRESS 2008 SITE PHONE # WITH AREA CODE r f c -(Am CITY STATE -a ZIP CODE # OF TANKS AT SITE CITY CA 952 2 CIRCLE WORK TO BE DONE CONTRACTOR ICC # APPLICANT BILLING NAME TANK ID # (s): APPLICANT CONTACT NAME l FliTF"I !� ,'�L r I1L APPLICANT MAILING ADDRESS 2008 APPLICANT PHONE # WITH AREA CODE i,� '� r L -CQ -] CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # $550 FEE INCLUDES FACILITY FEE + 1 TANK (2009) Closure Installation R air Retrofit ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $315 / TANK 2004 2005 2006 2007 2008 2009 $ $500 FEE INCLUDES FACILITY FEE + 1 TANK (2003-2008) $ PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) 1 $550 FEE INCLUDES FACILITY FEE + 1 TANK (2009) $ $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 ALL -Mi wn rukn %,ntf-n Check and Construction Ir PLAN CHECK FEE = $840 / FACILITY REPAIR PLAN CHECK TANK ID # (s) : $ CONSULTATION FEE _ $ 105/ HOUR $ TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $ s ill buckets, sum s, 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 ILL 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 RECEIVEDCHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 02123/09)