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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,5igov.or <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> R"( t <br /> CITY pp STATE I ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT fillgiiWG NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> TL3+J CIA Closure Installatio epa RetrofitlO <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 12008 2009— <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2003-2008) <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK( <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=$24.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$315/TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s) TEMPORARY CLOSURE FEE_$315/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s). PLAN CHECK FEE_$840/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE _ $315/FACILITY (use for monitoring equipment,cold starts, EVR upgrades, $ <br /> spill buckets,sumps misc.) s- <br /> PIPING REPAIR FEE =$315/FACILITY use forpiping,under-dispenser containment,ect. 3�s`�' <br /> MISCELLANEOUS <br /> TRANSFER FEE = $20 EEEE$ <br /> CONSULTATION FEE = $ 105/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $ 1051 HOUR <br /> SAMPLING INSPECTION FEE _ $ 105/HOUR <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVEDCHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02/23/09) <br />