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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sgov.org/ehd FACILITY NAME FACILITY CONTACT NAME FACILITY A DRESS SITE PHONE#WITH AREA CODE l CITY STATE ZIP CODE I #OF TANKS AT SITE Udi CA APPLICANT BILLING NAME APPLICANT CONTACT NAME '<s X11 APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE 1 . b CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# Closure Installation a a Retrofit ACTIVE FACILITY 2003 2004 2005 2006 2007 2008 $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) $ $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 FEE=$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. $ 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 CHECK# RECEIVED BY DATE RECEIVED SR EH 23 032(REVISED 7/18/08)