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1 SAN JOAQUIN COUNTV <br />ENVIRONMENTAL HEALTId DEPARTMENT <br />600 East Main Street, StoCkton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov,org/ctld <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />el r �n-n P" -N- <br />�r r c_ <br />P�iw� l-'>„'61 1 vry <br />FACILITY ADDRESS <br />2010 <br />SITE PHONE # WITH AREA CODE <br />(-1 ' r <br />-- Ot PCr� <br />CITY <br />I STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />(11L>nl <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2.011) <br />ICA <br />9 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />CLOSURE FEE_ = $375 / TANK <br />2006 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PMONE # WITH AREA CODE <br />2009 <br />2010 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO SE DONE <br />CONTRACTOR ICC # <br />Closure Installation Re air Retrofit <br />I �--i <br />AUTIVE FACIhtTY <br />TANK ID # s <br />CLOSURE FEE_ = $375 / TANK <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />$ <br />$500 FEE INCLUDES FACILITY FEE+ 1 TANK (2006.2007) <br />PIPING REPAIR FEE = $375 / FACILITY (use for pi ing, under -dispenser containment, ect.) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2.011) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM =$49.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # s <br />CLOSURE FEE_ = $375 / TANK <br /># TANKS X $375;; <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : =TEMPORARY <br />CLOSURE FEE = $375 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID A (s) ; <br />$ <br />$ <br />TANK RETROFIT REPAIR FEE n $375 / FACILITY (use for monEtoring equipment, cold starts, EVR upgrades, <br />-75 <br />s III buckets sums misc. <br />SAMPLING INSPECTION FEE = $ 125/ HOUR 1 <br />$ <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY (use for pi ing, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />TRANSFER FEE $ 25 <br />$ <br />CONSULTATION FEE _ $1251 HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR 1 <br />$ <br />ALL FEES ARE BASED ON 1 nC SUB HOURL:f FRATE. E. I iME THAT I EXCEEDS FEES MAID WILT. BE BILLED To APPLICANT. <br />TOTAL, AMOUNT DUE $ K-1 J I <br />