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SAN JOAQUIN COUNTY 00P1 ENVIRONMENTAL HEALTH DEPARTME 00 East Main Street,Stockton,CA 95202- Telephone:(209)468-3420 Fax:(209)468-3433 Web:www sjgov.or //eehd FACILITY NAME FACILITY CONTACT NAME FA LIN ADD 90S SITE PHONE#WITH AREA CODE told ;)- MrDl CITY STATE ZIP CODE #OF TANKS AT SITE APP ICANTBILLING NAME APPLICANT CONTACT NAME aatL AP T CANT PHONE# (AREA CODE APPLICANT MAILING ADDRESS 1-1 �30c),L CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACT�ICC# Closure Installation;e air Retrofit ACTIVE FACILITY 2004 2005 2006 2007 2008 2009 $500 FEE INCLUDES FACILITY FEE+1 TANK(2004-2007) $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2009) $ $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED $ TANK SURCHARGE=$15/TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place $ TANK ID#(s): CLOSURE FEE_$315/TANK #TANKS X$315= TEMPORARY CLOSURE Plan Review and Inspections) $ TANK ID#(s): TEMPORARY CLOSURE FEE=$315/FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) $ TANK ID#(s): PLAN CHECK FEE=$840/FACILITY REPAIR PLAN CHECK TANK ID#(s): $ TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, spill buckets,sumps,misc.) $ PIPING REPAIR FEE _$315/FACILITY use for piping,under-dispenser containment,ect.) MISCELLANEOUS TRANSFER FEE _ $20 $ CONSULTATION FEE = $ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $105/HOUR $ SAMPLING INSPECTION FEE _ $105/HOUR ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY S ERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED R EH 23 032(REVISED 03120109)