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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3"Floor,Stockton,CA 95202-2708 <br /> Telephone.(209)468-3420 Fax(56floor):(209)468-3433 Web:www.sjgov.ore/ehd <br /> FACILITY NAME _ FACILITY CONTACT NAME <br /> FACT ITY ADDRESS SITE PHONE#WITH AREA CODE <br /> <✓ 2�C Zo 3 fOZ <br /> CITY/� STATE 21P CODE #OF TANKS AT SITE <br /> ` CA ©!✓ <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLIC T MAILING ADDRESS APPLICANT PHONE#WITHGAKFADE5�2-0 �C�C c/. eo � l CITY STATE LP CODE CIRCLE WORK TO BE DCONTRACTOR ICC#C" C 76 osure Installation Repair <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 2000 2001 2002 2003 2004 2005 <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANKSURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK10# s CLOSURE FEE_$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> PLAN CHECK FEE_$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$2791 FACILITY use for monitodng equipment,spill buckets,tank sumps,misc. $ <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR $ <br /> SAMPLING INSPECTION FEE = $93/HOUR $ <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02/22/05) <br />