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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME <br /> 304 East Weber Avenue,3d Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(5`h floor):(209)468-3433 Web:www.sigov.or <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITEPHONE#WITH AREA CODE <br /> CITY. I STATE I ZIP CODE --[12F TANKS AT SITE <br /> e P <br /> LCA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS ` APPLICANT PHONE#WITH AREA CODE <br /> fgc'n Oom q7 q <br /> CITYSTATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> U �r Closure Installation epa' Retrofit 1<" ac�J <br /> ACTIVE FACILITY <br /> 2000 2001 2002 2003 2004 2005 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK <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=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE_$279/TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY use for monitoring equipment,s ill buckets,tank sumps,misc. <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $93/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE $93/HOUR <br /> SAMPLING INSPECTION FEE $93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICEREQUEST# FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02/22/05) <br />