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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTM <br />600 East Main Street, Stockton, CA 95202-09 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />FACILITY ME <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />Installs as of 8/1/07) <br />$125 PER TANK AFTER FIRST TANK <br />E <br />FACILITY=WITH <br />2003 <br />2004 <br />�l <br />FACILITY�(ADDRE <br />2007 <br />SITE PHOA CODE <br />qc <br />CITY <br />STATE <br />( ' r <br />ZIP CODE # �OF TANKS AT SITE <br />CITY <br />STATEZIP CODE <br />CA <br />QJ D <br />AP ICA T BILLING NAME <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />Installs as of 8/1/07) <br />$125 PER TANK AFTER FIRST TANK <br />APPLI T CONTACT NAME <br />2003 <br />2004 <br />�l <br />A PLICANT MAILING ADDRE <br />2007 <br />APPLICANT PHONE # WITH AREA CODE <br />007) <br />CITY <br />STATEZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />��5� <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />Installs as of 8/1/07) <br />$125 PER TANK AFTER FIRST TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <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 PLAN CHECI <br />(Plan Check and Construction I <br />TANK ID # (s) : <br />REPAIR P <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for <br />PIPING REPAIR FEE = $294 / FACILITY (use for <br />TRANSFER FEE = $ 20 <br />CONSULTATION FEE = $ 98/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />SAMPLING INSPECTION FEE = $ 98/ HOUR <br />ALL FEES ARE BASED ON THE $98 HOURLY RATE. TIME THAT EXCEE <br />OFFICE USE ONLY <br />PLAN CHECK FEE = $784 / FACILITY <br />PAID <br />buckets, tank s <br />nisc.) I <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY I DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 08/3/071 <br />