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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:www.sjRov.org/ehd <br /> FACILITY <br /> NAM <br /> �E f FA ILITY,CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH ARE COPE <br /> STATE ZIP CODE #OF TANKS AT SITE <br /> CITY �j <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING AD RESS APPLICANT PHONE#WIT AREA CODE <br /> (p w c' <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> CA IClosure Installation Repair <br /> etrofit Oij .w <br /> ACTIVE FACILITY <br /> 2002 2003 2004 2005 2006 2007 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2)C08°�•ie�v $ <br /> ,;i <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$294/TANK #TANKS X$294= <br /> TEMPORARY CLOSURE <br /> Plan Review and inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$2941 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) $ <br /> TANK ID#(s): PLAN CHECK FEE=$784/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $ <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,s ill buckets,tank sumps,misc.) $ <br /> PIPING REPAIR FEE _$294/FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $98/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR <br /> SAMPLING INSPECTION FEE = $98/HOUR <br /> ALL FEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID --tAMOUNT RECEIVED I CHECK I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 0813107) <br />