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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMID <br />600 East Main Street, Stockton, CA 95202-30, <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />FACILITY NAME FACILITY CONTACT NAME <br />APPLICANT CONTACT NAME '. <br />FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br />16\ : t 01 <br />CITY I STATE I TJP CODE <br /># OF TANKS AT SITE <br />CA <br />APPLICANT PHONE # WITH AREA CODE <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME '. <br />ELtT <br />2006 <br />� n C. �v <br />APPLICANT MAILING <br />ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) <br />Y <br />CITY <br />STATE <br />ZIP CODE I CIRCLE WORK IR BE DONE <br />CONTRACTOR ICC # <br />Closure Installation it Retrofit <br />$125 PER TANK AFTER FIRST TANK <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br />2006 <br />2007 2008 2009 <br />2010 <br />- <br />2011 <br />spill buckets, sumps, misc.) <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) <br />$ <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 CUPA PROGRAM =$49.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br /># TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />INSTALLATION PLAN <br />(Plan Check and Const <br />TANK ID # (s) : <br />PLAN CHECK FEE = <br />/ FACILITY <br />REPAIR PIAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />r~ <br />spill buckets, sumps, misc.) <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 $ <br />C6NSULTATION FEE = $ 125/ HOUR $ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $125/HOUR $ <br />SAMPLING INSPECTION FEE _ $ 125/ HOUR $ <br />ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE $ <br />OFFICE USE ONLY <br />x <br />