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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 ff'cb: www.sil'ov.ortt/ehd <br />FACILITY NAME FA ILITY CONTA A E <br />FACT TY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />CITY STATE ZIP CODE # OF TANKS AT SITE <br />C1 CA <br />APPLICANT BILLING NAM APPLI NT CONTACT NAME <br />AP CAT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />CITY <br />ST TE ZIP CODE . CIRCLE WORK TO BE. DONE CONTRACTOR ICC # <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2003-2D08) 2004 2005 2006 2007 2008 2009 <br />$S50 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 />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s <br />TEMPORARY CLOSURE CLOSURE FEE _ $315) TANK # TANKS X $315 = $ <br />Plan Review and Inspections) <br />TANK ID # (s) : TEMPORARY CLOSURE FEE _ $3151 FACILITY $ <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK 1D # (s) PLAN .CHECK FEE _ $840 / FACILITY $ <br />REPAIR PLAN CHECK <br />TANK ID # (s) <br />TANK.RETROFITREPAIR FEE _ $315 / FACILITY (use for monitoring equipment, bold starts, EVR upgrades, <br />$ <br />-- - _.- <br />spill- buckets, sumps, mise) <br />PIPING REPAIR FEE _ $315 7 FACILITY (use for pi in , under-dispenser containment, ect. <br />$ <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 />