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SAN JOAQUIN COUNTY <br />` ENVIRONMENTAL HEALTH DEPARTME <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />F'ACCILLIITTYY NAME FACIrLITY CONTACT NAME <br />cA <br />FACILITY ADDRESS `1 <br />SITE PHONE # WITH AREA CODE <br />CITY STATE ZJP CODE <br /># OF TANKS A <br />CA <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />�I�r ti <br />rPL;IGA7�NT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />uJ1Cat,�n <br />CITY STATE ZJP CODE CIRCLE WORK VQ BE DONE CONTRACTOR ICC # <br />Closure Installation Rkepair Retrofit <br />TIVE FACILITY0 <br />F <br />FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) 2006 2007 2008 2009 2010 2011 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) <br />$125 PER TANK AFTER FIRST TANK $ <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 CLOSURE FEE = $375 / TANK # TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections <br />$ <br />TANK ID # (s) : TEMPORARY CLOSURE FEE = $375 / FACILITY <br />$ <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s): <br />PLAN CHECK FEE= $1,000/ FACILITY <br />$ <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />PTANKROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />ill bkets, sum s,mise. <br />FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$s <br />315PAIR <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />$ <br />ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE <br />$ <br />OFFICE USE ONLY <br />