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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 Web: www.sjgov.orLy/ehd <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />I 1 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE# WITH AREA CODE <br />FACILITYADDRESSADDRESS <br />33� <br />ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />PHONE # WITH�AREA CODE <br />Closure Installation Repair Retrofit <br />L o h <br />CITY <br />D a <br />STATE <br />CA <br />ZIP ODE # OF TANKS AT SITE <br />$ <br />TANK PENALTY ASSESSED <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />d(Ia <br />I 1 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE# WITH AREA CODE <br />C-) <br />CITY STATE <br />33� <br />ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />2011 <br />Closure Installation Repair Retrofit <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 />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) <br />$125 PER TANK AFTER FIRST TANK <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />$ <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 =$49.00/ FACILITY <br />$ <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) : <br />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 />PIPING REPAIR FEE = $375 / FACILITY (use for piping, under-disnenser rnntalnmant pmt I I zl, <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE _ $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />ALL FEES ARE BASED ON THE $125 Nr1nRt v RATE TIOAr- TWAT <br />$ <br />TOTAL AMOUNT DUE <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 0811111 by KF) <br />