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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEP <br />600 East Main Street, Stockton, CA 95202-3k,. <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s' ov.or /ehd <br />c>(U <br />FACILITY NAMES, <br />FACILITY CONTACT NAME <br />(t C- <br />k - <br />FACILITY A DRESS <br />SITE PHONE # WITH AREA CODE <br />25�v�ilal�lrat� Cf�.. �Cc��r"1 <br />1• <br />CITY STATE <br />St`C. C1 CA <br />ZIP CODE # OF TANKS AT SITE <br />Cr—n t�) <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />25�v�ilal�lrat� Cf�.. �Cc��r"1 <br />1• <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO 8 DONE <br />CONTRACTOR ICC # <br />Closure Installation air Retrofit <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) 2006 2007 2008 2( <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) <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 ACUPA PRnr;RAM <br />9 1 2010 1 2011 <br />00/ <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 />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />T---] <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : PLAN CHECK FEE = $1,000 / FACILITY $ <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, misc. <br />PIPING REPAIR FEE _ $375 / FACILITY use fori in , under -dispenser containment, ect. $ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 $ <br />CONSULTATION FEE = $ 125/ HOUR $ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 125 / HOUR $ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR $ <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 />4 <br />