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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.sjRoy.orgjehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> S kak <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> W GLCCt_0_*- <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PFIONE#WITH AREA CODE <br /> 00 (.qtt) Q-f� - a 3 T <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> S <br /> Closure cLov CIA Jk_ e Installation (Ja ai Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2003-2008) 2004 2005 2006 [2007 2008 2009 <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2009) <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 INA CUPA PROGRAM=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$3 #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Insp2ctio2.sj <br /> TANK ID#(s): TEMPORARY CLOSURE FEE $3' $ <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): _7 PLAN CHECK FEE $840/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets,sumps,misc.) <br /> lF <br /> PIPING REPAIR FEE =$315/FACILITY use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE $20 $ <br /> CONSULTATION FEE $105/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE $ 105 1 HOUR $ <br /> SAMPLING INSPECTION FEE = $105/HOUR $ <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED --CHECK# RECEIVED BY DATE RECEIVED <br /> SIR <br /> EH 23 032(REVISED 02123/09) <br />