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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 <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />;IBX r o <br />4 Fon No - <br />FACILITY ADDRESS <br />SITE PHONE # WITH ARE ODE <br />c1 <br />y -� <br />CITY <br />STATE <br />ZIP CODE <br />I # OF TANKS AT SITE <br />f <br />CA <br />nF?,Q- <br />STATE <br />APPLICANT BILLING NAME <br />TANK ID # (s): <br />APPLICANT CONTACT NAME <br />IV <br />2007 <br />s <br />fn t{ I1cr <br />APPLI NT <br />AILING ADDRESS <br />$ <br />APPL CANT PHONE # WITH AREA CODE <br />ti c <br />U4 <br />CITY <br />STATE <br />ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />' <br />+I Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />$ <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) <br />PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br /># TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : <br />PLAN CHECK FEE = $1,000 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />$ <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />spill buckets, sumps, misc. <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />$ <br />$ Y J <br />PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />$ <br />ALL FEES AHE BASED UN ME $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE $ <br />OFFICE USE ONLY <br />