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A 7�5of -4a1 -9g1cp 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.or ehd ' '•'' 1 Vale.Q FcM Mari G- ks - FACILITY CONTACT NAME - n r FACILITY ADDRESS SITE PHONE # WITH AREA CODE ( I a--ri i I I -er CITY STATE ZIP CODE # OF TANKS AT SITE \ CA CITY APPLICANT BILLING NAME TANK ID # (s): APPLICANT CONTACT NAME V ( I a--ri i I I -er APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2011 $ -C�33� CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # ''1 CA Closure Installation Re air Retrofit ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $375 / TANK 2006 2007 2008 2009 2010 2011 $ $500 FEE INCLUDES FACILITY -FEE + 1 TANK (2006-2007) PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. 1 $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) $ $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 =$49.00/ FACILITY $ PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $375 / TANK # TANKS X'$375 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $375 / FACILITY Check I TANK ID # (s) : I PLAN CHECK FEE = $1,000 / FACILITY I $ REPAIR PLAN CHECK TANK ID # (s) : $ $, TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR spill buckets, sumps, misc.) SAMPLING INSPECTION FEE = $ 125/ HOUR $ $ PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. MISCELLANEOUS TRANSFER FEE _ $ 25 $ CONSULTATION FEE = $ 125/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR $ SAMPLING INSPECTION FEE = $ 125/ HOUR $ ALL FEES ARE BASED ON THE $i25 HOURLY RATE. E. I IME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. TOTAL AMOUNT DUE $ OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED EH 23 032 (REVISED 0811111 by KF)