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r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.or /p ehd FACILITY NAME FACILITY CONTACT NAME FACILITY ADDRESS SITE PHONE#WITH AREA CODE CITY STATE ZIP CODE #OF TANKS AT SITE CA APPLICANT BILLING NAME APPLICANT CONTACT NAME APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# Closure Installation Repair Retrofit ACTIVE FACILITY 2005 2006 2007 2008 2009 2010 $500 FEE INCLUDES FACILITY FEE+1 TANK(2005-2007) $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2008-2010) $ $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED TANK SURCHARGE=$15/TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID# s CLOSURE FEE=$366/TANK #TANKS X$366= TEMPORARY CLOSURE Plan Review and Inspections) TANK ID#(s): TEMPORARY CLOSURE FEE=$366/FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) $ TANK ID#(s): PLAN CHECK FEE=$976/FACILITY REPAIR PLAN CHECK TANK ID#(s): TANK RETROFIT REPAIR FEE =$366/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, spill buckets,sumps,misc. PIPING REPAIR FEE _$366/FACILITY use for piping.under-dispenser containment,ect. MISCELLANEOUS TRANSFER FEE _ $25 CONSULTATION FEE _ $ 122/HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $122/HOUR SAMPLING INSPECTION FEE = $122/HOUR ALL FEES ARE BASED ON THE$122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED SR EH 23 032(REVISED 07/21/10)