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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 /g ehd FACILITY NAME FACILITY CONTACT NAME Cly_'foKxf) wv C, FACILITY ADDRESS SITE PHONE # WITH AREA CODE l '5 . C �v , - CITY STATE I ZIP CODE # OF TANKS AT SITE c CA C APPLICANT BILLING NAME APPLICANT CONTACT NAME E I wv C, APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE b65 Wbam NNE 2010 CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # Closure Installation Re air Retrofit ACTIVE FACILITY TANK ID # (s):CLOSURE FEE= $375 !TANK # TANKS X $375 = $500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) $125 PER TANK AFTER FIRST TANK 2006 2007 2008 2009 2010 2011 $ $ 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= $375 !TANK # TANKS X $375 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $375 / FACILITY ALLATION PLAN CHECK Check and Construction Ir I TANK ID # (s) : I PLAN CHECK FEE = $1,000 / FACILITY I � REPAIR PLAN CHECK TANK ID # (s) : $ TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, s ill buckets, sum s, misc. $ 3�S PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.)$ $ MISCELLANEOUS TRANSFER FEE _ $ 25 $ CONSULTATION FEE = $ 125/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR $ SAMPLING INSPECTION FEE = $ 125/ HOUR ALL FEES ARE BASED ON THF 5175 Hni ion v onrc -RA r $ -- -- - - -- • •---•- • •� • �• • •••� .. i LXULLUS FEES PAID WILL BE BILLLU 10 APPLICANT. TOTAL AMOUNT DUE $ OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED I RECEIVED BY I DATE RECEIVED EH 23 032 (REVISED 08/1/11 by KF)