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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.or /�ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> C U �Cc� nd <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 5 . Ch e,fo f)c _3 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> V ,, \ <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> Z -(j5 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation p 'r Retrofit N)71 A <br /> ACTIVE FACILITY •v l l S� <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2003-2008) 2004 2005 2006 2007 2008 2009 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009) <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=$24.00/FACILITY $ <br /> PER;ANET CLOSURE <br /> RemPermitted Closure in PlaceTANCLOSURE FEE_$315/TANK #TANKS X$315= $TEMY CLOSURE <br /> (Plan and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$315/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$840/FACILITY $ <br /> [REPAIR PLAN CHECKK ID#(s): <br /> K RETROFIT REPAIR FEE _$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> s ill_buckets,sum s,mist. <br /> PIPING REPAIR FEE _$315/FACILITY (use for pipin ,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $105/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $105/HOUR $ <br /> SAMPLING INSPECTION FEE _ $105/HOUR $ <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# I RECEIVED BY I DATE RECEIVED <br /> ISR <br /> EH 23 032(REVISED 02/23/09) <br />