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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEJ <br /> 600 East Main Street,Stockton,CA 95202-30 9 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orWehd <br /> FACILITY N FACILITY CONTACT NAME <br /> GlA H.l <br /> FACILITY D S SITE PHONE#W H AREA CODE <br /> OO <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> ICA q:§3"�Ao <br /> APPLICANT_DILLIDW NAME APPLICAN ONTA T NAME <br /> APPLIC AILING ADDRESS APPLICANT PHONE# ITH AREA CODE <br /> P l- 33 -,;L- <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) 2002 2003 2004 2005 006 2007 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008&New <br /> Installs as of 8/1/07) $ <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=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$294/TANK #TANKS X$294= $ <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$294/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$784/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,s ill buckets,tank sumps,misc.) $ <br /> PIPING REPAIR FEE _$294/FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $98/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR $ <br /> SAMPLING INSPECTION FEE = $98/HOUR $ <br /> ALL FEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 8321REVISED nR111n71 <br />