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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENIO <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s,)gov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />S qca — — � <br />-^ <br />3-b C <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />7 17 S T <br />2 -OR) to( <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />tt <br />S ` <br />CA <br />ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />APPLICANT BILLINN�G- N/A <br />TANK ID # (s): <br />APPLICANT CONTACT NAME <br />-ME (l <br />2005 <br />2006 <br />APPLICANT MAILING ADDRESS <br />2008 <br />APPLICANT PHONE # WITH AREA CODE <br />152-1 -E <br />Zo s—RSs f <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />O <br />2� <br />(3S3(p <br />Closure Installation Repa r Retrofit 52504 5 r - V <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $345 / TANK <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) <br />PIPING REPAIR FEE = $345 / FACILITY (use for piping, under -dispenser containment, ect.) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />SAMPLING INSPECTION FEE _ $ 115/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <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 = $345 / TANK <br /># TANKS X $345 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $345 / FACILITY <br />4LLATION PLAN CHECK <br />Check and Construction Ir <br />TANK ID # (s) : I PLAN CHECK FEE = $920 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TRANSFER FEE _ $ 20 <br />TANK RETROFIT REPAIR FEE = $345 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, misc. <br />is <br />PIPING REPAIR FEE = $345 / FACILITY (use for piping, under -dispenser containment, ect.) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 115/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />SAMPLING INSPECTION FEE _ $ 115/ HOUR <br />ALL FEES ARE BASED ON THE $115 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 />SR <br />EH 23 032 (REVISED 07/01/09) <br />i <br />