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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.si ov.org/ehd <br />FAC LITY NAME�/ <br />FACILITY CONTACT NAM <br />-' v4�V 1C�t. �,� <br />AJ <br />e <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />2010 <br />2011 <br />CITY STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />�l CA <br />mut U <br />Closure Installatioge"RepaiA Retrofit <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />-' v4�V 1C�t. �,� <br />', is `may <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2010 <br />2011 <br />CITY STATE <br />ZIP CODE <br />CIRCLE WORK T DONE CONTRACTOR ICC # <br />' <br />- L <br />Closure Installatioge"RepaiA Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />2012 <br />$ <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE= $15 /TANK <br />$ <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 CH <br />(Plan Check and Construct <br />TANK ID # <br />PLAN CHECK FEE = $1000 / F, <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />s ill buckets, sum s, misc. <br />$ <br />PIPING REPAIR FEE = $3751 FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />S <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />ALL FEES ARE BASED ON THE Nx unnoi v o <br />$ <br />---- ••••--^---•�•���.. inao lnhl cAGEEDS FEF--SPAIDWILLBE BILLEDTO APPLICANT. <br />TOTAL AMOUNT DUE $ <br />OFFICE USE ONLY <br />SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED777# I RECEIVED BY I DATE RECEIVED <br />EH 23 032 (REVISED 04/13/12 by KF) <br />