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SAN JOAQUIN COUNTY ��I n <br /> ENVIRONMENTAL HEALTH DEPAR <br /> 600 East Main Street,Stockton,CA 95202-30 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Wear www.sj ov.or /g ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> _ e1 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA (i <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> WlF,1y. I �c1Gv X M u)"Wf v <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 25T-i 5C0a.-V)r-) 1. <br /> CITY STATE ZIP CODE CIRCLEWORKTO DONE CONTRACTOR ICC# <br /> Closure Installation gtpaVRetrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2006-2007) 2006 2007 2008 2009 2010 2011 <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 A CUPA PROGRAM=$49.00/FACILITY $ <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 /> Pian Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <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 itoring equipment,cold starts,EVR upgrades, <br /> s ill bucketmons sumps,misc. <br /> PIPING REPAIR FEE_$375/FACILITY use for piping,under-dispenser containment,ect. $ <br /> -------- ----------- <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 /> OFFICE USE ONLY $ <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# <br /> RECEIVED BY DATE RECEIVED <br /> EH 23032(REVISED 08/1/11 Y KF) <br /> 4 <br /> i r <br />