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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN <br />600 East Main Street, Stockton, CA 95202-3027 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj o� /eehhd <br />FACILITY MME <br />APPLICANT INTACT NAME <br />FACILITY CON <br />CT NAM <br />/Im J) <br />4-7 10)1'//) <br />APPLICANT PHONE # WITH AREA CODE <br />pAhl <br />2006 <br />FACILITY ADDRESS <br />ATE <br />SITE PHON # WITH AREA CODE <br />q56 <br />CONTRACTOR ICC # <br />y3d-lve <br />CITY <br />STATE <br />ZIP CODE <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br /># OF TANKS AT SITE <br />CA <br />b/A <br />APPLICA ILL AME <br />APPLICANT INTACT NAME <br />CLOSURE FEE _ $294 / TANK <br />2002 <br />AP (CANT MAILIN DRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2005 <br />2006 <br />CITY <br />ATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />$ <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s) : <br />CLOSURE FEE _ $294 / TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 98 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />$ <br />Installs as of 8/1/07) <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 =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s) : <br />CLOSURE FEE _ $294 / TANK <br /># TANKS X $294 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE _ $294 / FACILITY <br />INSTALLATION PLAN CHEC <br />(Plan Check and Construction <br />TANK ID # (s) : <br />PLAN CHECK FEE _ $784 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE _ $294 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />$ ` <br />PIPING REPAIR FEE _ $294 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS <br />$ <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 $au HOURLY RATE. T7ME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 /REVISED OR/3/071 <br />