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SAN JOAQUIN COUNTY • <br /> ONVIRONmENTAL HEALTH,DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www sieov.orpLehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> � ') <br /> CITY <br /> STATE ZIP CODE #OF TANKS AT SITE <br /> APPLICAN--------------- <br /> BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS A PLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repai Retrofit <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2004-2007) $ <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2009) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15 <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID# s CLOSURE FEE=$315/TANK #TANKS X$315= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) $ <br /> TEMPORARY CLOSURE FEE_$315!FACILIT <br /> TANK ID#(s): Y <br /> INSTALLATION PLAN CHECK <br /> Plan Check a�ndCons�lwctionns ections TANK ID#(sPLAN CHECK FEE_$840!FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $ <br /> TANK RETROFIT REPAIR FEE _$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc.)$ <br /> PIPING REPAIR FEE _$315/FACILITY (use for piping,under-dispenser containment,ect.) <br /> MRANSFERFEE <br /> $ <br /> _ $20 $ <br /> FEE _ $105/HOUR RELEASE EVALUATION FEE _ $1051 HOURECTION FEE _ $105/HOUR <br /> ALL FEES ARE BASED ON THE$105 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 /> ISR <br /> EH 23 032(REVISED 03120109) <br />