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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj og v.or /,g ehd <br />FACILITY NAME <br />FACILITY] CONTACT NAME <br />CLOSURE FEE = $345 / TANK <br />t �} <br />FACILITY ADDRESS <br />SITE PHON ITH AREA CODE <br />6' <br />i <br />CITY <br />STATE ZIP CODE <br />I # OF TANKS AT SITE <br />I1,0ACA <br />CONTRACTOR ICC # <br />I <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />CLOSURE FEE = $345 / TANK <br />0M DA <br />APPLE AILING ADDRESS <br />APP ANT PHONE # WITH AREA CODE <br />2007 <br />SIO <br />CITY <br />STAT!7 <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />I <br />Closure Installation Repair Retrofit <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) <br />$125 PER TANK AFTER FIRST TANK <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $345 / TANK <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />SAMPLING INSPECTION FEE _ $ 115/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $345 / TANK <br /># TANKS X $345 <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $345 / FACILITY <br />INSTALLATION PLAN CHEC <br />(Plan Check and Construction <br />TANK ID # (s) : I PLAN CHECK FEE = $920 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $345 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />TRANSFER FEE _ $ 20 <br />spill buckets, sumps, misc. <br />$ <br />PIPING REPAIR FEE = $345 / FACILITY (use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 115/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />SAMPLING INSPECTION FEE _ $ 115/ HOUR <br />ALL FEES ARE BASED ON THE $115 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />