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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.sjjzov.orL-/ehd <br />S. [-&567 <br />CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) 2003 2004 2005 2006 2007 2008 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) <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 />TANK ID # s CLOSURE FEE _ $315 / TANK # TANKS X $315 = $ <br />TEMPORARY CLOSURE <br />_. _. _ <br />Plan Review and Ins coons <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 />s ill buckets, sumps, misc. <br />PIPING REPAIR FEE = $315 / FACILITY (use for piping,under-dispenser containment, ect.) $ <br />'FICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # I RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 7/18/08) <br />