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SAN JOAQUIN COUNTY <br />WNVIRONMENTAL HEALTH DEPARTMEN <br />600 East Main Street, Stockton, CA 95202-302 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj ov.or /F ehd <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />CLOSURE FEE = $294 / TANK <br />• <br />' <br />r <br />, <br />PIF <br />I WWI <br />OiTsi 14 111 Vdlil Q <br />LW-1111:201540MI <br />ZIP CODE <br />• � <br />CONTRACTOR ICC # <br />$ <br />itall• <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />•• <br /># OF TANKS AT SITE <br />�y <br />$ <br />Installs as of 8/1/07) <br />$125 PER TANK AFTER FIRST TANK <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />CLOSURE FEE = $294 / TANK <br />2002 <br />PLICANT MAILING ADDRESS <br />APPtfCWNT PF[09E # WITH AREA CODE <br />2005 <br />® - <br />CITY <br />STE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />$ <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s) : <br />CLOSURE FEE = $294 / TANK <br />2002 <br />2003 <br />12004 <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 />Check and Construction I <br />TANK ID # (s) <br />PLAN CHECK FEE = $784 / FACILITY 1 $ I <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 />tea_ i —1 — I IrvIC 1 nM 1 CAI.CCUa rCCa rAIU VVILL [5t MLLrU 1 V Atr LIUAN 1. <br />C•}dd[•3�I�9�•��IAI <br />SERVICE REQUEST # I FACILITY ID I AMOUNT RECEIVED I CHECK # I RECEIVED BY I DATE RECEIVED <br />1 SR <br />EH 23 032 /REVISED 08/3/071 <br />