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SAN JOAQUIN COUNTY <br /> 4WENVIRONMENTAL HEALTH DEPARTME�0 <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax. (209)468-3433 Web:www.sjgov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FA L I ADD RE SITE PHONE#WITH AREA CODE <br /> aow- <br /> CIT? I STATE ZIP CODE #OF TANKS AT SITE <br /> �du;c I CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> .1 .)A4,v>-J JA444Z A&iZ42. <br /> APPLIGANLING ADDRESS APPLICANT PHONE 9 WITH AREA CODE <br /> CITY SIATIE ZIP CODE CIRCLE WORK TO Br`DONE I CONTRACTOR ICC <br /> Closure Installation a it Retrofit [�Z 7 <br /> AA' <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK(2004-2007) <br /> $550 FEE INCLUDES FACILITY FEE+I TANK(2008-200-9, <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* I CLOSURE FEE=$345 TANKS X$345 <br /> TEMPORARY CLOSURE <br /> (Plan Review and Ins coons <br /> TANK ID#(s): TEMPORARY CLOSURE FEE $345 FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspeclions) <br /> TANK ID#(s): PLAN CHECK FEE $920 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =$345/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc.) <br /> PIPING REPAIR FEE $345/FACILITY use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE $20 $ <br /> CONSULTATION FEE = $115/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $115/HOUR $ <br /> SAMPLING INSPECTION FEE = $115/HOUR $ <br /> ALL FEES ARE BASED ON THE$115 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST#: FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY 11 RECEIVED <br /> SIR <br /> EH 23 032(REVISED 07101109) <br />