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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTM <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.org/ehd <br />FACILITY NAME 4 <br />FACILITY CONTACT NAME <br />b <br />® <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />APPLIC AILING ADDRES <br />2006 <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />CITY t j <br />CA <br />I ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />APPLICANT ILL G 14AME <br />TANK ID # (s): <br />APPLICANT ONTACT NAME <br />® <br />2003 <br />R // <br />APPLIC AILING ADDRES <br />2006 <br />APPLICANT PHONE # WITH A A CODE <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />/ —(o3,3 <br />CITY t j <br />I STATE <br />I ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />w11 CCGC ADG �ACG11 Awl Ttt-?nn ..�...�. •• e-.�� -....� �...� �..�____ ____ <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 />w11 CCGC ADG �ACG11 Awl Ttt-?nn ..�...�. •• e-.�� -....� �...� �..�____ ____ <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 />4LLATION PLAN CHR <br />Check and Construction <br />TANK ID # (s) : I PLAN CHECK FEE = $784 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE = FACILITY use for monitoring equipment, spill buckets, tank sumps, misc.) <br />$ <br />` <br />PIPING REPAIR FEE _ / 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 />w11 CCGC ADG �ACG11 Awl Ttt-?nn ..�...�. •• e-.�� -....� �...� �..�____ ____ <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID I AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 !REVISED 0813/071 <br />