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., �0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sj og v.or /�ehd FACILITY NAME FACILITY CONTACT NAME FACILITY ADDRESS SITE PHONE#WITH AREA CODE CITY STATE ZIP CODE #OF TANKS AT SITE CA APPLICANT BILLING NAME APPLICANT CONTACT NAME at) APPLICANT MAILING_-Alt ADDRESS APPLICANT PHONE# H AREA CODE ® K 2 J CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# Closure Installation Repairtrofit t 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=$49.00/FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID#(s): CLOSURE FEE=$345/TANK #TANKS X$345= TEMPORARY CLOSURE Plan Review and Inspections) TANK ID#(s): TEMPORARY CLOSURE FEE_$345/FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID#(s): PLAN CHECK FEE_$920/FACILITY REPAIR PLAN CHECK TANK ID#(s): TANK RETROFIT REPAIR FEE =$345/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ spill buckets,sumps,misc. PIPING REPAIR FEE _$345/FACILITY use for piping,under-dispenser containment,ect. MISCELLANEOUS TRANSFER FEE _ $20 CONSULTATION FEE _ $115/HOUR UNAUTHORIZED RELEASE EVALUATION FEE _ $115/HOUR SAMPLING INSPECTION FEE _ $115/HOUR ALL FEES ARE BASED ON THE$115 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATER SR EH 23 032(REVISED 07/01/08)