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SAN JOAQUIN COUNTY is <br />EsNVIRONMENI'AL HEALTIi Di:PARTMENf <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Far. (209) 468-3433 Web: wwwAgov.or d chd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />V'Es vzo <br />Ngmi) > G�+Ptvl:�Att <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />q01 W. t'tc- <br />2011 <br />CITY <br />I STATE <br />ZIP CODE I # OF TANKS AT SITE <br />CIRCLE WORK TO BE DONE <br />CA <br />c? 5-2—'-1 v I t= ---x 6;--: -rte tr-r, <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />14 t S rs-o (,c i AJ�L �,`it-t <br />k 14 " Aets Qu P ac>Ctii <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2010 <br />2011 <br />CITY <br />STATE <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br /><> <br />1 <br />> s,�--i <br />Closure Installation repall Retrofit <br />lo, <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />2012 <br />$ <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) <br />1 <br />1 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br /># TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : <br />PLAN CHECK FEE = $1000 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID#(s): <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, mise. <br />$ <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $125/ HOUR <br />$ <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 />