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SAN JOAQUIN COUNTY 0 ENVIRONMENTAL HEALTH DEPARTMEW 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sj og v.or /g ehd FACILITY NAME FACILITY CONTACT NAME FACILITY ADDRESS SITE PHONE 0 WITH AREA C E MCCtt -Wt t CITY I STATE ZIP CODE. . #OF TANKS AT SITE v CA 7 APPLICANT BILLING NAME APPLICANT CONTACT NAME. APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA`CODE CITYSTATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# Closure Installationepair Retrofit TaI0 ACTIVE FACILITY $500 FEE INCLUDES FACILITY FEE+1 TANK(2003-2008) 2004 2005 2006 2007 2008 2009 $550 FEE INCLUDES FACILITY FEE+1 TANK(2009) $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED $ TANK SURCHARGE=$15/TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID# s CLOSURE $315/TANK #TANKS X$315= $ TEMPORARY CLOSURE Plan Review and Inspections) TANK ID#(s): TEMPORARY CLOSURE FEE=$315/FACILITY $ INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID#(s): PLAN CHECK FEE=$840/FACILITY $ REPAIR PLAN CHECK TANK ID#(s): TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ spill buckets,sumps,misc.)j PIPING REPAIR FEE _$315/FACILITY use for piping,under-dispenser containment,ect. $ MISCELLANEOUS TRANSFER FEE _ $20 $ CONSULTATION FEE = $105/HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE _ $105/HOUR $ SAMPLING INSPECTION FEE = $105/HOUR $ ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CHECKV RECEIVED BY DATE RECEIVED SRWN EH 23 032(REVISED 02/23/08)