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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (5`h floor): (209) 468-3433 Web: www.slpov.org/ehd <br />FACILITY NAME FACILITY CONTACT NAME <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br />STATE <br />CITY <br />STATE ZIP CODE <br /># OF TANKS AT SITE <br />Closure Installation Repair Retrofit <br />CA <br />2006 <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />CITY <br />STATE <br />ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />2002 <br />2003 <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />2001 <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />$ <br />CLOSURE FEE = $285 / TANK <br /># TANKS X $285 = <br />TANK ID # (s): <br />TEMPORARY CLOSURE <br />Plan Review and Inspections)$ <br />TEMPORARY CLOSURE FEE = $285 / FACILITY <br />TANK ID # (s) : <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections)$ <br />PLAN CHECK FEE = $760 / FACILITY <br />TANK ID # (s) : <br />REPAIR PLAN CHECK <br />TANK ID # s <br />$ <br />TANK RETROFIT REPAIR FEE = $285 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />Z <br />PIPING REPAIR FEE = $285 / FACILITY <br />(use for piping, under -dispenser containment, ect.) <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED I CHECK # I RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 07/28/06) <br />