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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTM <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web: www.sigov.org/ehd <br /> FACILITY NAMEFACILITY CONTACT N ME <br /> J U - ( ' a--,I ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY SIAM ZIP CODE #OF TANKS AT SITE <br /> CA � <br /> APPLI L G NAM APPLIC ICONTACT NAME <br /> i <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> e5�' 1 mJ I 46"-6A51-37 <br /> CITY STATE—f ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> 1 �a0S- Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) 2002 2003 2004 2005 2006 2007 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008 8 New <br /> Installs as of 8/1/07) $ <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 /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE_$294/TANK #TANKS X$294= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$294/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHEC�FeE �$784FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$294 FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) 3 <br /> PIPING REPAIR FEE =$294/FACILITY (use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $98/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $98/HOUR $ <br /> SAMPLING INSPECTION FEE = $98/HOUR $ <br /> ALL FEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 0813107) <br />