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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME <br /> 1868 E.Hazelton Ave., Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fitt•:(209)468-3433 Web: www.sjcehd.com <br /> FACILITY NAME FACILITY.CONTACT NAME <br /> FAC DRESSSITE PHONE# ITH AREA <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> f } Itl '!� CA v! <br /> APPLICANT IL ING NA E APPLICAN ONTACT NAME <br /> AP ( NT MAILING ADDRESS APPLICANT P, NE#WITH AREA CODE <br /> i <br /> CITY STATE ZIP CODE CIRCLE WORK rO BE DONE CONTRACTOR ICC# <br /> ` o Closure Installation Re air Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007-2008) 2007 2008 2009 2010 2011 2012 <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=$49.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$375/TANK #TANKS X$375= $ <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 stare 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# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 04113/12 by KF) <br />