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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 952.05-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />2007 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />FACILITY ADDRESS <br />7-7 7 <br />SITE PHONE # WITH AREA CODE <br />CIRCLE WORK TO 13E DONE CONTRACTOR ICC # <br />C.1 I lyr-Ll 7-- <br />Closure Installation Repair Retrofit T5 31Z-7ff'? <br />CITY <br />STATE <br />ZIP CODE I # OF TANKS AT SITE <br />CA <br />q r2v-" <br />APPLICANT BILLING NAM_ E <br />APPLICANT CONTACT NAME <br />CLOSURE FEE = $3751 TANK # TANKS X $375 = <br />2007 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2010 <br />7-7 7 <br />CITY StATE I ZIP CODE <br />CIRCLE WORK TO 13E DONE CONTRACTOR ICC # <br />C.1 I lyr-Ll 7-- <br />Closure Installation Repair Retrofit T5 31Z-7ff'? <br />ACTIVE FACILITY <br />TANK ID # s <br />CLOSURE FEE = $3751 TANK # TANKS X $375 = <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />2012 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $151 TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00! FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # s <br />CLOSURE FEE = $3751 TANK # TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 I FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />$ <br />TANK ID # (s) PLAN CHECK FEE = $1000 1 FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEEC- $375 ACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />37�7, <br />spill buckets, sum , mise. <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 1251 HOUR <br />PIPING REPAIR FEE = $3751 FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEF = $ 1251 HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 1251 HOUR <br />$ <br />ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE I $ <br />OFFICE USE ONLY <br />