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. SAN JOAQUIN COUNTY <br /> ENviRoNMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web;wwwAgov.orPlehd <br /> FACILITY ME FACILITY 2914TACT NAME <br /> FACILITYADDRESS SITE PHORE#WITH ARE ODE <br /> I mnu., . - <br /> CITY STATE P CODE #OF TANKS AT SITE <br /> CA (150/b <br /> APPLICANT BILLING NAME APPLICANT CONTAICT NAME - <br /> APPLICA LING ADDRESS APPLICANT PHONE#WITH AREA ODE <br /> C95W �a-rn a 4 - <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2005 2006 2007 2008 2009 2010 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2005-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2010) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE_$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$49.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$366/TANK #TANKS X$366= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$366/FACILITY <br /> INSTALLATION PLAN CHECK - - <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$876/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> $ <br /> TANK RETROFIT REPAIR FEE _$ /FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> split buckets,sumps,miser) F1O� <br /> PIPING REPAIR FEE = 6/FACILITY use for piping,under-dispenser containment,act. $!J/✓� <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 <br /> $ <br /> CONSULTATION FEE _ $122/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $122/HOUR <br /> SAMPLING INSPECTION FEE _ $122/HOUR <br /> ALL FEES ARE BASED ON THE$122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SIR <br /> EH 23 032(REVISED 07/21/10( <br />