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r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone. (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.org/ehd FACILITY NAME FACILITY CONTACT NAME e i , FACILITY ADDRESS SITE P ONE # WITH AREA CODE ma r -� CITY STATE I ZIP CODE''ff # OF TANKS AT SITE CITY STATE ZIP CODE CIRCLE WORK TO BE DONE APPLICANT BILLING NAIVIE TANK ID # (s): APPLICANT.CONTACT NAME 2005 2006 TEMPORARY CLOSURE FEE = $366 / FACILITY APPLICANT MAILING ADDRESS 2010. APPLICAN PHONE # WITH AREA CODE $500 FEE INCLUDES FACILITY FEE + 1 TANK (2005-2007) PIPING REPAIR FEE = $366 / FACILITY use for piping, under -dispenser containment, ect.) CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # a CClosure Installation Repair Retrofit ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $366 / TANK # TANKS X $366 = 2005 2006 TEMPORARY CLOSURE FEE = $366 / FACILITY 2008 2009 2010. spill buckets, sumps, misc.) $500 FEE INCLUDES FACILITY FEE + 1 TANK (2005-2007) PIPING REPAIR FEE = $366 / FACILITY use for piping, under -dispenser containment, ect.) $ 12007 -$ 550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2010) $ - $25 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED $ TANK SURCHARGE = $15 /TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY $ PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $366 / TANK # TANKS X $366 = TEMPORARY CLOSURE Plan Review and Inspections TANK ID # (s) : TEMPORARY CLOSURE FEE = $366 / FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) -TANK-ID #'-(s) — - - - - _ -T--- PLAN CHECK FEE -1976 / FACILITY_ -- REPAIR PLAN CHECK TANK ID # (s) : $ CONSULTATION FEE = $ 122/ HOUR $ TANK RETROFIT REPAIR FEE = $366 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $ spill buckets, sumps, misc.) $ PIPING REPAIR FEE = $366 / FACILITY use for piping, under -dispenser containment, ect.) $ MISCELLANEOUS TRANSFER FEE _ $ 25 $ CONSULTATION FEE = $ 122/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 122 / HOUR $ SAMPLING INSPECTION FEE _ $ 122/ HOUR Afi oeoe AOC -----.—„1.,..,...-A-- -...__..__________.._ $ )FFICE USE ONLY SERVICE REQUEST #FACILITY ID --[-AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 07/21/10)