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SAN JOAQUIN COUNTY <br /> ENONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sj.Rov.org'/ehd <br /> FACILITY NAME FACILITY CONTACT NAME As <br /> FACILITY DRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT <br /> AP LICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2008 2009 2010 2011 2012 2013 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007-2008) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009-2012) <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=$35.00/FACILITY <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <br /> bs <br /> TANK ID#(s): CLOSURE FEE=$375/TANK j #TANKS X$375= S <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$375/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$1000/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,sumps,misc.) <br /> PIPING REPAIR FEE _$375/FACILITY (use for piping, under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE _ $ 125/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $125/HOUR $ <br /> SAMPLING INSPECTION FEE = $125/HOUR <br /> ALL FEES 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 /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY I DATE RECEIVED <br /> EH 23 032(REVISED 1/16/2013 by KF) <br />