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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEO <br />304 last Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (r floor): (209) 468-3433 Web: www.sigov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />CLOSURE FEE = $279 / TANK <br />2000 <br />FACILITY ADDRESS <br />SITS PH N # WITH AREA CODE <br />♦ 7w <br />2004 <br />CITY STATE <br />ZIP C DE <br />I # OF TANKS AT SITE <br />CA <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />CLOSURE FEE = $279 / TANK <br />2000 <br />APPLICANT A GAD RESS <br />AFFPCICANT PHONE # WITH REA CODE <br />2003 <br />2004 <br />ITY STATE <br />Z CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />Closure Installation Repai Retrofit <br />$ <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $279 / TANK <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />2005 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <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): <br />CLOSURE FEE = $279 / TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />PLAN CHECK <br />Check <br />TANK ID # (s) : <br />PLAN CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment spill buckets tank sumps, misc.) <br />$ <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 02/22/05) <br />n4o <br />