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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 /�ehd <br />FACILITY NAME <br />TANK ID # (s): <br />FACILITY CONTACT NAME <br />2003 <br />2004 <br />2005 <br />FACILITY ADDRE S <br />2007 <br />–9[T—EPRONE # WITH AREA CODE <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />9 - -1 <br />CITY <br />I STATE <br />ZIP CODE��f <br />F TANKS AT SITE <br />Lc <br />CA <br />8535/6 <br />APPLICANT BILLAG NAME <br />TANK ID # (s): <br />APPLICANT CONTACT NAME <br />2003 <br />2004 <br />2005 <br />APPLICANT MAILING ADDRESS <br />2007 <br />APPLICANT PHONE # WITH AREA CODE <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$ <br />CITY <br />STATE <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />l i <br />Closure Installation epai Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE _ $315 / TANK <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$ <br />PIPING REPAIR FEE _ $315 / FACILITY use forpiping, under -dispenser containment, ect. V <br />SAMPLING INSPECTION FEE _ $ 105/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE _ $15 / TANK <br />Is <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 _ $315 / TANK <br /># TANKS X $315 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE _ $315 / FACILITY <br />TANK ID # (s) : I PLAN CHECK FEE _ $840 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TRANSFER FEE _ $ 20 <br />TANK RETROFIT REPAIR FEE _ $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, misc.)% <br />$ <br />PIPING REPAIR FEE _ $315 / FACILITY use forpiping, under -dispenser containment, ect. V <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 105/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 105 /HOUR <br />SAMPLING INSPECTION FEE _ $ 105/ HOUR <br />ALL r CGA NKr oADCU UN 1 Kr 41709 HUUKLT KA 1 C. I IMC I FIAT mm mr-UJ rccJ rruu vvILL or mi -Lau v rirru�.wv �. <br />OFFICE USE ONLY <br />' <br />