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® SAN JOAQuIN COUNTY Is RECEIVED <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sicehd.com APR 2 9 2015 <br />WRT1111= <br />FACILITY CONTACT NAME <br />- <br />ADDRESSff <br />FACILITY <br />• •D <br />APPLICANT MAJILING ADDRESS <br />r <br />%o el) <br />f de)/5 3 7 <br />CITY <br />STATE <br />ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />VPA <br />aA <br />APPLICANT MAJILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />%o el) <br />f de)/5 3 7 <br />CITY <br />STATE <br />ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />7� <br />Closure Installation a Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />2012 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />7� <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM =$49.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br /># TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />Check and Construction <br />TANK ID # (s) : <br />PLAN CHECK FEE = $1000 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TRANSFER FEE _ $ 25 <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, misc. <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />7� <br />9 <br />MISCELLANEOUS <br />$ <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 />ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE Is -375- <br />OFFICE USE ONLY <br />