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•SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM 600 East Main Street, Stockton, CA 95202-4019 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/eh FACILITY NAME FACILITY CONTACT NAME APPLICANT CONTACT%N/AME�" y (j {.1 �L� •moi -ii... L-C''l' pa FACILITY ADDRESS SITE PHONE # WITH AREA CODE APPLICANT MAILING ADDRESS 2006 CITY STATE ZIP CODE # OF TANKS AT SITE CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE APPLICANT BILLL�IINNG- NAME TANK ID # (s) : APPLICANT CONTACT%N/AME�" y (j {.1 �L� •moi -ii... L-C''l' pa 5 r c' a L�CI� o � APPLICANT MAILING ADDRESS 2006 APPLICANT PHONE # WITH AREA CODE $500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) $ CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # ( $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New 3 I)CI Closure Installation Repair Retrofit ACTIVE FACILITY TANK ID # (s) : CLOSURE FEE = $294 / TANK 2002 2003 2004 2005 2006 2007 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR $ SAMPLING INSPECTION FEE = $ 98/ HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New $ Installs as of 8/1/07) $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 = $294 / TANK # TANKS X $294 = TEMPORARY CLOSURE (Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $294 / FACILITY INSTALLATION PLAN CHECK (Plan Check and Construction Ir TANK ID # (s) : PLAN CHECK FEE = $784 / FACILITY REPAIR PLAN CHECK TANK ID # (s): $ TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) $� PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect.) $ MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 98/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR $ SAMPLING INSPECTION FEE = $ 98/ HOUR ALL FEES AKE CASED ON THE $8S HUUKLY KATE. 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 08/3/071