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Ic.0t> © `-)t:5 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.or FACILITY NAME FACILITY CONTACT NAME a Cid FACILITY ADDRESS SITE PHONE # WITH AREA CODE 2003 APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE CITY STATE ZIP CODE I # OF TANKS AT SITE CITY iSTATE CA 90 APPLICANT BILLING NAME I APPLICANT CONTACT NAME CLOSURE FEE _ $315 / TANK 2003 APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2006 a CITY iSTATE ZIP CODE CIRCLE WORK TO BE DONE TCONTRACTOR ICC # PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.)$ Closure Installation Repair Retrofit $ ACTIVE FACILITY TANK ID # (s): CLOSURE FEE _ $315 / TANK 2003 2004 2005 2006 2007 2008 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) $ PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.)$ $ SAMPLING INSPECTION FEE = $ 105/ HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) $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 an Review andlns ections TANK ID # (s) : TEMPORARY CLOSURE FEE = $315 / FACILITY INSTALLATION (Plan Check and TANK ID # (s) : I PLAN CHECK FEE = $840 / FACILITY REPAIR PLAN CHECK TANKID # (s) : $ TRANSFER FEE _ $ 20 $ 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 _ $ 105/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE =$105/HOUR $ SAMPLING INSPECTION FEE = $ 105/ HOUR ALL r==b AKE UAS=D UN 1 HE :$1U5 HUUKLY RATE. TIME THAT EXCEED5 FEE5 PAID WILL 6E BILLED 1 LIAPPLIGAN I.