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SAN JOAQUIN COUNTY <br />• ENVIRONMENTAL HEALTH DEPART* <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone. (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.or /Jehd <br />FACILI I Y NAME <br />I FACILITY CONTACT NAME <br />TEMPORARY CLOSURE <br />11 <br />SITE PHONE # WITH AREA CODE <br />FAC ILI ADD ESS <br />t <br />CITY STATE I <br />ZIP CODE # OF TANKS AT SITE <br />-c co- <br />CA <br />Lt �.. 3 <br />ZIP CODE <br />APPLIUANI BILLING NAME <br />APPLICANT CONTACT NAME <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 981 HOUR <br />$ <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />�-tcc V 6,1 <br />�_� <br />t�, � j <br />Closure Installation Repair Retrofit <br />2002 2003 2004 2005 2006 2007 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 8 New <br />Installs as of 8/1/07) $ <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 =$24.00/ FACILITY $ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s) : CLOSURE FEE = $294 / TANK # TANKS X $294 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />INSTALLATION <br />(Plan Check and <br />TANK ID # (s) : <br />PLAN CHECK FEE = $784 / FACILITY I $ <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 98/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 981 HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 98/ HOUR <br />ALL FEES ARE BASED ON THE $98 HOURLY RATE TIMP TWAT CVr--- <br />$ <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # TECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 08/3/071 <br />