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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.sigoy gr /g ehd FACILITY NAME FACILITY CONTACT NAME APPLICANT CONTACT NAME L, AC I Y ADDRESS SITE PHONE # WITH AREA CODE APPLICA MAILING ADDRESS 0 CITY I STATE ZIP CODE # OF TANKS AT SITE A, I CA STATE APPLICANT BILLING NAME TANK ID # (s): APPLICANT CONTACT NAME 2A J 2005 2006 APPLICA MAILING ADDRESS 2008 PPLICANT PHONE #WITH AREA CODE / CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # SAMPLING INSPECTION FEE _ $ 105/ HOUR Closure Installation epi etrofit ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $315 / TANK 2004 2005 2006 2007 2008 2009 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) SAMPLING INSPECTION FEE _ $ 105/ HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) $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 CHEC (Plan Check and Construction TANK ID # (s) : I PLAN CHECK FEE = $840 / FACILITY REPAIR PLAN CHECK TANK ID # (s) : TRANSFER FEE _ $ 20 TANK RETROFIT REPAIR FEE = $315 / FACILITY (use f ' ring equipment, cold starts, EVR upgrades, spill bucket 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 I DATE RECEIVED SR EH 23 032 (REVISED 03/20/09)