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SAN JOAQUIN COUNTY <br /> ow <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-302, <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sj ov.or /g ehd <br /> FACILITY NAME FACILITY CONT CONTACT NAME <br /> FA ILITY DR E nSS i o � - ' <br /> SITE PHONE#WITH A A CODE <br /> GIN STATE I ZIP CODE <br /> #-OF TANKS'AT SITE <br /> I 1-6o CA q5 <br /> APPLICANT BILLING NAMEI APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS__ APPLICANT PHONE#WITH AREA CODE <br /> clrr <br /> STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> C Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2006 2007 2008 2009 2010 2011 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2006-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2011), $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK $ <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 CLOSURE FEE $375/TANK #TANKS X$375= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections <br /> TANK ID#(s) TEMPORARY CLOSURE FEE_$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$1,000/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE $375(FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> s lll buckets sums misc.)� <br /> PIPING REPAIR FEE_$375/FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE $.25 $ <br /> CONSULTATION FEE _ $1125,'HOUR $ <br /> UNAUTHORIZED RELEASE`EVALUATION FEE' _ $125/HOUR $ <br /> SAMPLING INSPECTION FEE <br /> ALL FEES-ARE BASED ON THE$125 HOURLY RA HOUR <br /> THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT $ <br /> . <br /> TOTAL AMOUNT DUE <br /> OFFICE-USE ONLY $ <br /> SERVICE REQUEST# FACILITY,ID AMOUNTRECENED CHECK# <br /> RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 08M/11'by KF) <br />