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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone. (209) 468-3420 Fax: (209) 468-3433 Weh: www.sjizov.ora/ehd <br />NAWR <br />i <br />ILI <br />2005 <br />CITY STATE <br />ADDRESSFACILITY <br />i�n,'j�Tf <br />2009 <br />Closure Installatio epair Re fit <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />1 <br />$ <br />SAMPLING INSPECTION FEE _ $ 115/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2010) <br />APPLICANT BILLING NAME AP NT CONTACT NAME <br />i <br />AP LICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />2005 <br />CITY STATE <br />ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />2009 <br />Closure Installatio epair Re fit <br />AU I IVI: FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $345 /.TANK <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />1 <br />$ <br />SAMPLING INSPECTION FEE _ $ 115/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2010) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $345 /.TANK <br /># TANKS X $345 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $345 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Ir <br />I$ <br />TANK ID # (s) : PLAN CHECK FEE _ $920 /FACILITY <br />REPAIR PLAN CHECK <br />TANK ID#(s): <br />TANK RETROFIT REPAIR FEE = $345 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, misc. <br />PIPING REPAIR FEE = $345 / FACILITY — (useforpiping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 115/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 115/ HOUR <br />OFFICE USE ONLY <br />SR <br />EH 23 032 (REVISED <br />