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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjszov.org—/ebd FACILITY NAME FACILITY CONTACT NAME # TANKS X $315 = APPLICANT MAILING ADDRESS APPLICANT PHONE #WITH AREA CODE FACILITY ADDRESS SITE PHONE # WITH AREA CODE ZIP CODE CIRCLE WORK TO BE DONE - ) CITY STATE ZIP CODE I # OF TANKS AT SITE UNAUTHORIZED RELEASE EVALUATION FEE = $105 / HOUR CA $ APPLICANT BILLING NAME APPLICANT CONTACT NAME a TANK ID # (s): CLOSURE FEE _ $315 / TANK # TANKS X $315 = APPLICANT MAILING ADDRESS APPLICANT PHONE #WITH AREA CODE 4 61 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # 2008 Closure installation Repair Retrofit $500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) ACTIVE FACILITY TANK ID # (s): CLOSURE FEE _ $315 / TANK # TANKS X $315 = 2003 2004 2005 2006 2007 2008 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) UNAUTHORIZED RELEASE EVALUATION FEE = $105 / HOUR $ 1 $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) $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 =$24.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE _ $315 / TANK # TANKS X $315 = TEMPORARY CLOSURE Plan -Review and Ins ections TANK ID # (s) : TEMPORARY CLOSURE FEE = $315 / FACILITY TANK ID # (s) : I PLAN CHECK FEE = $840 / FACILITY $ REPAIR PLAN CHECK TANK ID # (s) : $ TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, spill buckets, sumps, misc.)v PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect. $ MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE _ $ 105/ HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $105 / HOUR $ SAMPLING INSPECTION FEE _ $ 105/ HOUR ALL 1-==b AKt bASCD UN 1 ht $705 NUUKLY KAit. 11ML TKAT tKULtUS tttb YAIU WILL tit UILLty SU Arrul.Ary 1. OFFICE USE ONLY SERVICE REQUESTLf ACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR` EH 23 032 (REVISED 7/18/08)