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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPART101. <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.or /g ehd <br />FAGILII Y NAME <br />I FACILITY CONTACT NAME <br />o C 6 %> <br />FACILITY ADDRESSI <br />ee, Zeg I <br />SITE PHONE # WITH AREA CODE <br />o r- t - <br />(e 0-y- at-rief <br />APPLICANT PHONE # WITH AREA CODE <br />CITY STATE I <br />ZIP CODE <br /># OF TANKS AT SITE <br />CA <br />C> <br />fJ j <br />APPL.IGANI BILLING NAME <br />TANK ID # (s): CLOSURE FEE = $294 /TANK # TANKS X $294 = <br />I APPLICANT CONTACT NAME <br />E114 <br />APPLICANT MAILING ADDRESS <br />GLC <br />(e 0-y- at-rief <br />APPLICANT PHONE # WITH AREA CODE <br />CITY <br />STATE I ZIP CODE <br />7 <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />L <br />fJ j <br />Closure Installation Repair Retrofit <br />is <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): CLOSURE FEE = $294 /TANK # TANKS X $294 = <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 2004 <br />2005 <br />2006 <br />2007 <br />SAMPLING INSPECTION FEE = $ 98/ HOUR <br />ALL FEES ARE BASED ON THE S98 HOURLY RnTF T1U= THAT vvr==n r <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): CLOSURE FEE = $294 /TANK # TANKS X $294 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />Check and Construction <br />TANK ID # (s) : <br />PLAN CHECK FEE = $784 / FACILITY <br />REPAIR PLAN CHECK <br />a <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY use for monitoring a ui ment, spill buckets, tank sumps, misc.)$ <br />$ <br />PIPING REPAIR FEE = $294 / FACILITY use for piping, under -dispenser containment, ect. <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <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 S98 HOURLY RnTF T1U= THAT vvr==n r <br />$ <br />- - - -- -- -- - •--•- • • •• � • �•..�.-..v . �w r ruu rn�t p� o1LLCv 1 v Nt'YLILHIV 1. <br />OFFICE USE ONLY <br />