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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMWP <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> C IITTYY <br /> Telephone. ( <br /> 209)469-3420 Fax. (209)4J6-8-34'3W3 <br /> web: - 1-7-Skigo– <br /> y.q <br /> rg/ <br /> ehd <br /> FACILITY NAME FACILITYCONTACT NAME <br /> FACILITY ADDRESS SITE PHONE W WITH AREA CODE <br /> STATE ZP CODE #OF <br /> TANKS AT SITE <br /> CA <br /> APPLICANT BILLING AME <br /> J110 46,;':2!j' APPLIC111 <br /> P� <br /> CONTACT NAME <br /> APPLICANT <br /> COAT MAILING ADDRESS NAME <br /> I - - <br /> APPL CANT PHONE#WITH AREA CODE <br /> CITY 5 4 <br /> STATE ZIP CODE <br /> %AM,U:VVQKK TO BE DO I CONTRACTOR ICC# <br /> if tG 0-1-* Closure Installation Reps! Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+I TANK(2002-2007) 2003 2004 2005 2006 2007 200 <br /> $550 FEE INCLUDES FACILITY FEE+I TANK(2008) <br /> $125 PER TANK AFTER FIRST TANK E0220:07) <br /> 0 <br /> $ <br /> TANK <br /> STATETIANK PENALTY ASSESSED $ <br /> TANK SURCHARGE TANK SURCHARGE $15/TANK $ <br /> S T SU C $ <br /> STATE SUERCHAR]GE FOR EFACILMES kl^T INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> ...(Rernoval or Permitted Closure in Place) <br /> TANK ID*(s): CLOSURE FEE $31 /TANK $ <br /> TEMPORARY CLOSURE #TANKS X$315 <br /> L_(Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE $315 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$840/FACILITY $ <br /> REPAIR PLAN CHECK =$ <br /> REPAIR AN CHECK <br /> P PL <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE $ <br /> TANK RETROFIT REPAIR FEE $315 FACILITY (use for monitoring equipment,Cold starts,EVR upgrades, <br /> s ill buckets,sum s,misc.) <br /> .i r <br /> PIPING REPAIR.FEE $315/FACILITY (use for P!pin2,under-dispenser containment,ect.) $ <br /> ............................................................................... <br /> MISCELLANEOUS <br /> 'SCELANEC <br /> TRANSFER FEE <br /> $20 <br /> CONSULTATION FEE <br /> S 105/HOUR $ <br /> UNAUTHORIZED <br /> RELEASE EVALUATION FEE ' 1051HOUR $ <br /> SAMPLING INSPECTION PI=r- $105/HOUR $ <br /> EXCEEDS <br /> ALL 1-11=11iii:b ARE BASED ON THE$1@5 HOURLY RATE. ME T EEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> REQUEST <br /> FACILITY 11 <br /> I SERVICE REQUEST# FACILITY IF A160—UNT---- <br /> SR CHECK K# RECEIVED BY ------- <br /> VIS <br /> EH 23 032(REVISED W118108) <br />