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SAN,Jt;AQU IN COUNTY <br /> NVIRONNGNTAL HFAL111 DEPAR"fliENT <br /> 600 L~ast Main Strect, Stockton, CA 9 202-3029 <br /> Telephone:(,209)468-3420 Fax:(209)463-3433 Web;:yw"v.,slgov.orelehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> f — \ — ------ -- <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLI ANT CONTACT NAME <br /> AP IGANT MAILING ADDRESS APPLICANT PHONE# 'WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> CloreInstallation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 12008 2009 <br /> $500 FEE INCLUDES FACILITY FEE= 1 TANK(2004-2007) <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK( $ <br /> 5125 PER TANK AFTER,FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=S15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENT OPV IN A CUPA PROGRAM=549.001 FACILITY <br /> PERhSAL1ENT CLOSURE <br /> (Removah r Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$3451 TANK 4 TANKS X 5345= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) 5 <br /> TANK ID#(s) TEMPORARY CLOSURE FEE=$3451 FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) $ <br /> TANK ID#(s) <br /> PLAN CHECK FEE=$92.0/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) S <br /> TANK RETROFIT REPAIR FEE _$345 1 FACILITY (use for monitoring equipment,cold starts, EVR Upgrades, <br /> spill buckets,sumps,mist.) - <br /> :5 <br /> PIPING REPAIR FEE _$3451 FACILITY (use for piping, under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE = s 20 $ <br /> CONSULTATION FEE = $ 1151 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = % 115/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE = S 1151 HOUR <br /> ALL FEES ARE BASED ON THE$115 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> rSR <br /> CE REQUEST p FAGII_ITY ID AhAOUNT <br /> EH 23 032(REVISED 07101109) <br />