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SAN JOAQUIN COUNTY <br />40 ENVIRONMENTAL HEALTH DEPARTMEN <br />600 East Main Street, Stockton, CA 95202-302 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj off; v.or /� ehd <br />Mal <br />APP ANT BILLING NAME 4 <br />FACILITY CONTACT <br />APPLICA CONTACT NAME <br />2002 <br />2003 <br />2004 <br />A��MIAILING ADDRESS <br />2006 <br />N ',, /m <br />cD�. r 0diV.,AIM- <br />#OFTANKSATSITE <br />.('2v I— <br />CI <br />STATE <br />Mal <br />APP ANT BILLING NAME 4 <br />TANK ID # (s) : <br />APPLICA CONTACT NAME <br />2002 <br />2003 <br />2004 <br />A��MIAILING ADDRESS <br />2006 <br />APPLICANT PHONE # WITH AREA CODE <br />cD�. r 0diV.,AIM- <br />OJ- <br />.('2v I— <br />CI <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s) : <br />CLOSURE FEE = $294 / TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />$ <br />Installs as of 8/1/07) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s) : <br />CLOSURE FEE = $294 / TANK <br /># TANKS X $294 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />Plan Check and <br />TANK ID # (s) : I PLAN CHECK FEE = $784 / FACILITY 1 <br />$ <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />�� r <br />PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 98/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />MLL rCCa MRC mMJCU VIV I nC .➢UO nVUMLT RMI C. I IIVIC 1 nM I r -M MMUJ t'CtJ VAIU VVILL Eft OILLLU I V AF FLIUAN I. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY I DATE RECEIVED <br />SR <br />