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AT SITE <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2005 2007) 2005 2006 2007 2008 2009 2010, <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2010) <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 =$49.00/ FACILITY $ <br />PERMANENT CLOSURE <br />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.sigov.orQ/ebd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />5 <br />Plan Review and Inspections <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />_701 C' <br />9�i3-t2q�, <br />CITY <br />J1 I STATE CODE # OF <br />.JI UCtfI C� <br />_ZIP <br />� <br />CA 15 2j• Y y <br />AT SITE <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2005 2007) 2005 2006 2007 2008 2009 2010, <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2010) <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 =$49.00/ FACILITY $ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />$ <br />TANK ID # (s): CLOSURE FEE = $366 / TANK # TANKS X $366 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE _ $366 /FACILITY <br />EINSTALLATION PLAN CHECK <br />k and Construction Ins ections (s)--- -- - -- _ --- - -- — PLAN CHECKFEE= $9767 FACILITY - <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $366 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $ <br />spill buckets, sumps, mist. <br />PIPING REPAIR FEE = $366 / FACILITY (use for piping, under -dispenser containment, ect-) $ <br />-MISCELLANEOUS <br />TRANSFER FEE _ $ 25 $ <br />CONSULTATION FEE = $ 122/ HOUR $ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 122 / HOUR $ <br />SAMPLING INSPECTION FEE = $ 122/ HOUR $ <br />ALL FEES ARE BASED ON THE $122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED I CHECK # RECEIVED BY DATE RECEIVED <br />SIR <br />EH 23 032 (REVISED 07121/10) <br />