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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.sjgov.or ehd FACILITY NAMEFACILITY TANK ID # (s): CONTACT NAME r e GC ��>>— l 0 C e- _ i Irv\ L�r� FACILITY ADDRESS I SITE PHONE # WITH AREA COPE 3330 1-330 to CITY CIRCLE WORK TO BE DONE STATE ZJP CODE I # OF TANKS AT SITE Closure Installation a air Retrofit CA S - APPLICANT BILLING NAME TANK ID # (s): APPLICANT CONTACT NAME 2006 ( SkQ APPLICANT MAILING ADDRESS I APPLICANT PfiONE # WITH AREA CODE I 1-330 CITY STATEI ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # r 9,_A-7 Closure Installation a air Retrofit ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $375 / TANK 2006 2007 2008 2009 2010 2011 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect. UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR $ SAMPLING INSPECTION FEE = $ 125/ HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) $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 =$49.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $375 / TANK # TANKS X $375 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $375 / FACILITY INSTALLATION PLAN CHECK (Plan Check and Construction Ir TANK ID # (s) : I PLAN CHECK FEE = $1,000 / FACILITY REPAIR PLAN CHECK TANK ID # (s) : t $ $3-7S.— 3-i5.TANK TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, spill buckets, sumps, misc. CONSULTATION FEE = $ 125/ HOUR PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect. UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR MISCELLANEOUS $ TRANSFER FEE _ $ 25 $ CONSULTATION FEE = $ 125/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR $ SAMPLING INSPECTION FEE = $ 125/ HOUR ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. TOTAL AMOUNT DUE $3� S, OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED EH 23 032 (REVISED 08/1/11 by KF)