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• AN UIN COUNTY <br /> S JOA Q <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ( Ui <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> Cts Jd '-(P'-'Ib. Dbl- <br /> CITY I STATE ZIPCODE #OF TANKS AT SITE <br /> CA �J <br /> APPLICANT BILLING NAME AP LICANT CONTACT'NAME <br /> APPLICANT MAILING AD RESS APPLICANT PHONE#WIT AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair etrofit <br /> ACTIVE FACILITY <br /> 2002 2003 2004 2005 2005 2007 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008 $ <br /> nta3+is .,f 8 .,'0 <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 /> $ <br /> TANK ID# s CLOSURE FEE_$294/TANK #TANKS X$294= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$294/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$784/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> $ <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoringequipment,spill buckets,tank sumps,mise) <br /> PIPING REPAIR FEE _$294/FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <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 EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# IV <br /> RECEED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 08/3107) <br />