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SAN JOAQUIN COUNTY # <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 Last Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.ora/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />e--�c� a r'I�. <br />Zl <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />APPLICANT MAILING ADDRESS <br />2010 <br />CITY STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />CA <br />2— <br />ATE ZIP CODE <br />APPLICANT BILLING NAME <br />TANK ID # (s): <br />APPLICANT CONTACT NAME <br />2006 <br />A <br />2008 <br />APPLICANT MAILING ADDRESS <br />2010 <br />APPLICANT PHONE # WITH AREA CODE <br />/d F- or <br />Cv� <br />� ..� l �� <br />CITY <br />ATE ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />��- <br />2— 1 <br />Closure Installation a ai Retrofit 1 <br />AL, IWE FHGILIIY <br />TANK ID # (s): <br />CLOSURE FEE = $3751 TANK <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />$ <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY use for pipiin, under -dispenser containment, ect, <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $3751 TANK <br /># TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK )D # (s) : <br />TEMPORARY CLOSURE FEE _ $375 1 FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Ir <br />TANK ID # (s) : PLAN CHECK FEE = $1,000 f FACILITY 1 $ <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />CONSULTATION FEE = $ 125! HOUR <br />$ <br />TANK RETROFIT REPAIR FEE = $375 1 FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets sumps, mist. <br />$ <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY use for pipiin, under -dispenser containment, ect, <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125! HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 1251 HOUR <br />All...�� �...��...� <br />$ <br />....ti I nr� -Lu vm Fnr- .712..5 HOURLT KATE. TWE THAT EXCEEDS FEES PAMWILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE $ <br />OFFICE USE ONLY <br />SERVICE REQUEST # I FACILITY ID AMOUNT RECEIVED I CHECKII RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 0611111 by KFI <br />