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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTIv t <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj og v_org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <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 />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />301 LA:) <br />(JM) 3b? .- s (,;,l <br />CITY <br />STATE I <br />ZIP CODE <br />I # OF TANKS AT SITE <br />CONTRACTOR ICC # <br />CA <br />c , 3qb <br />9 r---2 `I <br />APPLICANT BILLING NAME <br />I APPLICANT CONTACT NAME <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 />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />Gni... w 17r <br />01/ ) /&/ — 6, j;- � <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />/ <br />64r, r, k 4-r <br />6�1 <br />9 r---2 `I <br />Closure installation Repair Retrofit <br />TANK PENALTY ASSESSED <br />P%l I IV G!-PU111-1 I I <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 />$125 PER TANK AFTER FIRST TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />$ <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 />4LLATION PLAN <br />Check and Const <br />TANK ID # (s) : . I PLAN CHECK FEE = $784 / FACILITY $ <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, mise) <br />$ <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 Sm Hn11R1 v aero <br />$ <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SIR <br />EH 23 032 (REVISED 08/3!071 <br />