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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.sigov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE# TH AREA CODE <br /> CITY I STATE I ZIP CODE #OF TANKS AT SITE <br /> rCnCA 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILIN ADDRESS I APPLICANT PHONE#WITH AREA CODE <br /> dary) C,A) _ <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE ONE CONTRACTOR ICC# <br /> { f <br /> 177+W 647" Closure Installation epair R trofit <br /> ACTIVE FACILITY <br /> 2005 2006 2007 2008 2009 2010.. <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2005-2007) <br /> _$550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2010) <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# s CLOSURE FEE_$366/TANK #TANKS XA$366= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$366/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> --- ----------- <br /> TANICID#js).--- -- --- --- — —PLAN CHECK-FEE=$976 TFACILITY---- ---- --- — <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR-FEE _$366/FACILITY (use for monitoring equipment,.cold starts,EVR upgrades, $ <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE =$366/FACILITY use for piping,under-dispenser containment,ect.) $ <br /> --MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $122/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $122/HOUR $ <br /> SAMPLING INSPECTION FEE _ $122/HOUR $ <br /> ALL FEES ARE BASED ON THE$122 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 DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07/21/10)' <br />