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SAN JOAQUIN COUNTY <br />W <br />NVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-302 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj og v.or /g ehd PAYMENT <br />RECEIVED <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />2002 <br />DEC 13 2007 <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />2006 <br />ENVIRONMENTAL <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />CONTRACTOR ICC # <br />CA <br />TANK PENALTY ASSESSED <br />$ <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />2002 <br />2003 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2006 <br />2007 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />TANK PENALTY ASSESSED <br />$ <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />Installs as of 8/1/07) <br />$125 PER TANK AFTER FIRST TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />CONSULTATION FEE = $ 98/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />TANK PENALTY ASSESSED <br />$ <br />SAMPLING INSPECTION FEE = $ 98/ HOUR <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />(Removal or Permitted Closure in Place <br />TANK ID # (s) : <br />CLOSURE FEE = $294 / TANK <br /># TANKS X $294 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />INSTALLATION PLAN CHEC <br />(Plan Check and Construction <br />TANK ID # (s) : <br />PLAN CHECK FEE = $784 / FACILITY <br />REPAIR PLAN CHECK <br />AMOUNT RECEIVED <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />$ <br />PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS <br />AMOUNT RECEIVED <br />CHECK # RECEIVED BY <br />$ <br />TRANSFER FEE _ $ 20 <br />q <br />— 7j <br />$ <br />CONSULTATION FEE = $ 98/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 98/ HOUR <br />ALL FEES ARE BASED ON THE $98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID <br />AMOUNT RECEIVED <br />CHECK # RECEIVED BY <br />I DATE RECEIVED <br />sRuri <br />q <br />— 7j <br />j i sLj32L <br />EH 23 032 !REVISED 08/3/071 <br />