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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, ;CA 95205-6232 <br />Telephone: (209)468-3420 Fax: (209) 468-3433 Web: www.sicehd.com <br />FACILITY, NAME FACILITY CONTACT NAME <br />bF <br />FACILI ADDRESS SITE PHONE # WITH AREA CODE <br />-12 <br />12� 2 <br />CITY STATE ZIP CpDE # OF TANKS AT SITE <br />CA <br />TANK ID #s : CLOSURE FEE =$390 /TANK # TANKS X $390 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />( TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $390 / FACILITY <br />STATE <br />APPLICANT BILLINGNAME APPLICANT CONTACT NAME <br />t�C611 <br />APPLICANT MAILINGADDRESS APPLICANT PHONE # WITH AREA CODE <br />�l :6,M9, <br />CITY ZIP CODE CIRCLE WORK TO BE DONE CONTRACTORICC <br />Closure Installation Nair Retrofit <br />ACTIVE FACILITY <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK <br />$130 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />I STATE SURCHARGE FOR FACILITIES NOT A! <br />2009 2010 2011 2012 2013 2014 <br />ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY' <br />PERMANENT'CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID #s : CLOSURE FEE =$390 /TANK # TANKS X $390 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />( TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $390 / FACILITY <br />STATE <br />ACTIVE FACILITY <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK <br />$130 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />I STATE SURCHARGE FOR FACILITIES NOT A! <br />2009 2010 2011 2012 2013 2014 <br />ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY' <br />PERMANENT'CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID #s : CLOSURE FEE =$390 /TANK # TANKS X $390 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />( TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $390 / FACILITY <br />INSTALLATION <br />(Plan Check and <br />PLAN CHECK FEE = $1040 / FACILITY $ <br />REPAIR PLAN CHECK <br />TANK ID # (s) <br />TANK RETROFIT REPAIR FEE _ $390 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />—i" buckets, sumps, !misc. <br />PIPING REPAIR FEE = $390 / FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />TRANSFER FEE $ 25 <br />CONSULTATION FEE _ $ 130/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 130 / <br />SAMPLING INSPECTION FEE = $ 130/ HOUR <br />rets ARE BASED ON THE $13 <br />TOTAL AMOUNT DUE <br />R <br />FEES PAID WILL BE BILLED TO APPLICANT. <br />