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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPAR <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sizov.or //eehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> _ <br /> FACILITY ADDR SSSITE PHO #WIT AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA O` <br /> FAPP�gUCANT <br /> ANT BILLING NAME APPLICANT CONTACT NAME <br /> MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 14 <br /> Uwatatal� sCc�CK-�un _ <br /> CITY STATE ZIP CODE CIRCLE WORK T DONE CONTRACTOR dlcc# <br /> ICA I c Closure_Installation Re Ir Retrofit <br /> ACTIVE FACILITY <br /> - 2011 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2006-2007) 2006 2007 2008 2009 2010 <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 X49.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$375/TANK #TANKS X$375= $ <br /> TEMPORARY CLOSURE" <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$375 L.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,sum s,mist. <br /> PIPING REPAIR FEE_$375/FACILITY use for i in ,under-dispenser containment,ect. $ <br /> TRANSFER FEE $ <br /> CONSULTATION FEE $125/HOUR <br /> UNAl1THORIZEe_RELEASE EVALUATION FEE _ $125/HOUR $ -__ <br /> _ $ <br /> SAMPLING INSPECTION,FEE _ $125/HOUR <br /> "ALL-F-EES-ARE BASED ON THE$125-HOURLY RATE;TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> -OFFICE USE ONLY <br /> r7 . <br /> CE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEVED BY DATE RECEIVED <br /> 032.(REVISED 08/1/11 by KF) <br />