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SAN JOAQU IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029`® Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sisov.or ehd FACILITY CONTACT NAME FACILITY NAME SITE PHONE#WITH AREA CODE FACILITY ADDRESS E ZIP CODE #OF TANKS AT SITE AT CITY CA 11 11 APPLICANT BILLING NAME APPLII.CANT CONTACnnT NAME W ®� \ AP LICANT PHONE#WITH AREA CODE , A PL'ICCAtNTT MAILING ADDRESS C-0-—, — .�? V v o CIRCLE WORK TO BE DONE CONTRACTORIRICC# CIN STATE ZIP CODE _ ;�• C Closure Installation Repair Retrofit ACTIVE FACILITY 2004 2005 2006 2007 2008 200 $500 FEE INCLUDES FACILITY FEE+1 TANK(2004-2007) $ $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2009) $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 CLOSURE FEE_$315/TANK #TANKS X$315= TANK ID# s TEMPORARY CLOSURE $ Plan Review and Ins actions TANK ID#(s): TEMPORARY CLOSURE FEE_$315/FACILITY INSTALLATION PLAN CHECK $ Plan Check and Construction Ins actions PLAN CHECK FEE_$840/FACILITY TANK ID#(s): REPAIR PLAN CHECK TANK ID#(s): $ TANK RETROFIT REPAIR FEE _$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, s ill buckets,sum s,misc. $ PIPING REPAIR FEE =$315/FACILITY use for i in ,under-dis enser containment,ect.) MISCELLANEOUS $ TRANSFER FEE = $20 $ CONSULTATION FEE UNAUTHORIZED RELEASE EVALUATION FEE _ $105/HOUR $ SAMPLING INSPECTION FEE _ $1051 HOUR ALL FEES ARE BASED ON THE$10fi HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY ----.. T RECEIVED CHECK# RECEIVED BY DATE RECEIVED SERVICE RE4UEST# FACILITY ID SR EH 23 032(REVISED 03120109)