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SAN JOAQUIN COUNTY <br />`I' pAYMENT <br />ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED <br />600 East Main Street, Stockton, CA 95202-3029 ggP 2 2013 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ <br />I.I rnllNll' <br />FACILITY NAME NAMEHEALTH <br />DEPARTMENT <br />EFACILITYNTACT <br />FACILITY ADDRESS # WITH AREA CODE <br />2007 <br />CITY <br />STATE ZIP CODE <br /># OF TANKS AT SITE <br />CONTRACTOR ICC # <br />CA <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />TANK ID # s <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />2007 <br />CITY <br />STATE <br />ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />2012 <br />Closure Installation Repair Retrofit <br />$ <br />ACTIVE FACILITY <br />TANK ID # s <br />CLOSURE FEE = $375 / TANK <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />2012 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$ <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 IN A CUPA PROGRAM =$49.00/ FACILITY <br />PERMANENT CLOSURE <br />(Removal or Permitted Closure in Place) <br />TANK ID # s <br />CLOSURE FEE = $375 / TANK <br /># TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction In <br />TANK ID # (s)-* <br />PLAN CHECK FEE = $1000 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TRANSFER FEE _ $ 25 <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, misc. <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />ALL 1-ttb AKt tSAStU VN I Nt:.T-I LD tlUUKLT MAI C. I LLMC ITA I CA—. 0 I-- r.Ylu rrl�� oc ola_�w Iv nrr �w'.n �. <br />TOTAL AMOUNT DUE $ <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # I RECEIVED eY I DATE RECEIVED <br />EH 23 032 (REVISED 04/13/12 by KF) <br />