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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HE,.LTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 9202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjoov.oro/ehd <br /> FACILITY NAME FACILITY CONTACT NAM <br /> 7k�()9 rA-K a;V-� — [�'&QA- <br /> FACILITY ADMESS7 SIT HO WITH AREA CODE <br /> \ �05-1 uav� aS a <br /> CI S ATE ZIP CODE #OF TANKS AT SITE <br /> CCI CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAMING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> \V <br /> CITY S ATE ZIP CODE CIRCLE WORK TO BE DONECONTRACTOR ICC# <br /> Closure Installation Re ai Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007-2008) 2007 2008 2009 2010 2011 2012 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009-2012) $ <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): CLOSURE FEE=$375/TANK #TANKS X$375= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$375/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1000/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$375/FACILITY (use foc monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE _$375/FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $125/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $125/HOUR $ <br /> SAMPLING INSPECTION FEE = $125/HOUR $ S <br /> ALL FEES ARE BASED ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> i <br /> EH 23 032(REVISED 04/13/12 by KF) <br />