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- rAYi -201`t <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:w .sicehd.com <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 1 <br /> FACILITY ADDR S SITE PHONE#WITH AREA CODE <br /> 1 £ ( 2N) <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> CA q52 I <br /> APPLICANT BILLING NAME p APPLICANT CONTACT NAME <br /> ELr tU Cc 1 1�)� <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY <STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation fepor Retrofit <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK 2009 2010 2011 2012 2013 1 2014 <br /> $130 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 CUPA PROGRAM X35.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure In Place <br /> TANK ID#(s): CLOSURE FEE=$3901 TANK #TANKS X$390= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$390/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction inspections) <br /> TANK ID#(s): I PLAN CHECK FEE=$1040/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$390/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ '"t <br /> spill buckets,sumps,mist. Li <br /> PIPING REPAIR FEE=$390/FACILITY use for piping,under-dis22nser containment,mt. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $130/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $130/HOUR $ <br /> SAMPLING INSPECTION FEE = $130/HOUR $ <br /> FEES ARE BASED ON THE$130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY to I AMOUNT RECEIVED CHECKS RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 08-04-14) <br />