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0 SAN JOAQUIN COUNTY S <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov org/ehd, <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />2004 <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />l9 ("' Gl U{l1 i )1C_ S -t <br />-t 2> Z) <br />CITY STATE <br />I ZIP CODE # OF TANKS AT SITE <br />S- bac � CA <br />1 01 WS C1 <br />APPLICANT BILLING NA <br />APPLICANT CONTACT NAME <br />(e 0 relCA-'a 1, ii to— <br />2004 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />l9 ("' Gl U{l1 i )1C_ S -t <br />aor 4 L-4 L, �' b <br />CITY <br />S TE <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />3 1 + <br />CA -1 <br />-Ra ( <br />Closure Installation 41e�paO Retrofitj <br />-3 0 <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $345 / TANK <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />34 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) <br />$ <br />PIPING REPAIR FEE = $345 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />SAMPLING INSPECTION FEE = $ 115/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK <br />$ <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 =$49.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $345 / TANK <br /># TANKS X $345 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $345 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Ir <br />TANK ID # <br />PLAN CHECK FEE = $920 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />TANK RETROFIT REPAIR FEE = $345 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, mist.) <br />34 <br />$ <br />PIPING REPAIR FEE = $345 / FACILITY (use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 115/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 115/ HOUR <br />ALL FEES ARE BASED ON THE $115 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 07/01/09) <br />