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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENO <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> U) , ?�- <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> ! C 4A <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> (--- y CA <fc, L G <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY ATE ZIP CODE CIR LE WORK TO BE DON CONTRACTOR ICC# <br /> (� ct <br /> Closure Installation R air Retro t <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2004-2047) 2005 2006 2007 2008 2009 2010 <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(20013-2010) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00!FACit_ITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$345/TANK #TANKS X$345= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$3451 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$9201 FACILITY Is <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$3451 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets„sumps,misc. <br /> PIPING REPAIR FEE =$3451 FACILITY use for piping,under-dispenser Containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $ 5 OUR 11 1 H $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $115!HOUR <br /> SAMPLING INSPECTION FEE = $1151 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 I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVER <br /> SR <br /> EH 23 032(REVISED 01105110) <br />