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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.sigoy.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> A <br /> FACILITY A�SS SITE PHOW#WITH AREA CODE <br /> C _ �yI5 <br /> CITY <br /> STATE. ZIP CODE #OF TANKS AT SITE <br /> CA C <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> .t <br /> 'a unl*4)n3t�Ienc, e-grn ZmTf" <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2556- 5TOB mn 1, <br /> Dbffi <br /> CITY IsTATE ZIP CODE CIRCLE WORK T E DONE CONTRACTOR ICC# <br /> Closure installation Re it Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2006-2007) 2006 2007 2008 2009 2010 2011 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2011) <br /> $125 PER TANK AFTER FIRST TANK $ <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 /> E <br /> T CLOSUREPermitted Closure in Place TANKS X$375Y CLOSURE <br /> and Ins ections): TEMPORARY CLOSURE FEE_$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$1,000/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE_$375/FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> - - CONSULTATION FEE _ $125/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $125/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $125/HOUR $ <br /> ALL FEES ARE BASED ON THE-$125 HOURLY RATE. TIME-THATEXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY $ <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# <br /> RECEIVED BY DATE RECEIVED <br /> EH 23032(REVISED 08/1/11 by KF) <br />