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a <br />r I r r <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT v <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 <br />FACILITY CONTACT NAME <br />FLIM 3. <br />dam UJV\tTf a, <br />FACILITY ADDRESS I <br />SITE PHONE # WITH AREA CODE <br />Exd <br />k_ <br />CITY <br />CITY S ATE <br />I ZIP CODE # OF TANKS AT SITE <br />- A <br />TANK PENALTY ASSESSED <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />FLIM 3. <br />dam UJV\tTf a, <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />25t6 <br />k_ <br />CITY <br />STATE <br />ZIP CODE <br />I CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />TANK PENALTY ASSESSED <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) <br />$125 PER TANK AFTER FIRST TANK <br />2006 <br />2007 <br />2008 2009 <br />2010 <br />2011 <br />$ <br />SAMPLING INSPECTION FEE _ $ 125/ HOUR <br />ALLFEESARE RA5En AN THF -5199 WM IPI -v DAT. ru.cruwr ----------- .. <br />$ <br />- - - <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK $ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.001 FACILITY I <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />TEMPORARY CLOSURE CLOSURE FEE $375 /TANK # TANKS X $375 = $ <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 _ $1,000 / 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, sum s, mist. <br />PIPING REPAIR FEE _ $375 / FACILITY use for piping, under -dispenser containment, ect.) $ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />_ <br />CONSULTATION FEE- = $125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 125/ HOUR <br />ALLFEESARE RA5En AN THF -5199 WM IPI -v DAT. ru.cruwr ----------- .. <br />$ <br />- - - <br />TOTAL AMOUNT DUE <br />OFFICE USE ONLY <br />' SERVICE REQUEST # FA <br />a <br />4 1 � <br />41 <br />I t •I . �a� g kt y l aT �:. t • `y, 1. + x + x ' » I •x : a RA.4*I `C�. , y <br />fA�-i-F,'.' .te ••', I I ' 4ir' '•° s tsq,y. a+�q I ♦ + a � � A4� iao. y�1+• a <br />