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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.sjgov.or /g ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />CAt& Yi�& W ViCj& Cfj, <br />�1val[ml <br />FACILITY A}D--DRESS <br />SITE PHONE # WITH AREA CODE <br />2010 <br />CITY <br />I STATE <br />ZIP CODE # OF TANKS AT SITE <br />S��tw <br />CITY <br />fl 0 <br />APPLICANT BILLING NAME <br />Permitted Closure in Place <br />APPLICANT CONTACT NAME <br />w fo 6&in (', <br />1 L1(i <br />2008 <br />APPLICANT MAILING ADDRM <br />2010 <br />APPLICANT PHONE # WITH AREA CODE . <br />1110 ?0f6 <br />, S <br />(6 10) G'3b '25 bD <br />CITY <br />STATE ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR BCC # <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) <br />r>Installation Repair Retrofit <br />SQlosur-- <br />ACTIVE FACILITY <br />Permitted Closure in Place <br />�t?l <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) <br />TANK ID # (s) : <br />I TEMPORARY CLOSURE FEE = $375 / FACILITY <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />PERMANENT CLOSURE <br />Permitted Closure in Place <br />�t?l <br />$ <br />$ <br />TANK ID # s : <br />CLOSURE FEE _ $375 /TANK <br /># TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />I TEMPORARY CLOSURE FEE = $375 / FACILITY <br />ECK <br />Check <br />TANK ID # <br />PLAN CHECK FEE = $1,000 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />$ <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 /HOUR <br />spill buckets, sumps, misc. <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />$ <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 /HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />$ <br />ALL Fees ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE I $ �� <br />