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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.orp-/ehd FACILITY NAME TANK ID # (s): FACILITY CONTACT NAME 2004 elelwA/i %l A,- zad . FACILITY ADDRESS APPLICANT PHONE # WITH AREA CODE SITE PHONE # WITH AREA CODE $500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) CITY CITY STATE ZIP CODE # OF TANKS AT SITE CONTRACTOR ICC CA APPLICANT BILLING NAME TANK ID # (s): APPLICANT CONTACT NAME 2004 2005 2006 APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE ` 'ZY $500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) CITY PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC $550 FEE INCLUDES FACILITY FEE + 1 TANK (2003-2009) Closure Installation Repairetrofit 1 95� ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $315 / TANK 2004 2005 2006 2007 2008 2009 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) $ PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) $ SAMPLING INSPECTION FEE = $ 105/ HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2003-2009) $ $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 Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $315 / FACILITY Check and Construction TANK ID # (s) : I PLAN CHECK FEE = $840 / FACILITY I $ I REPAIR PLAN CHECK TANK ID # (s) : $ TRANSFER FEE _ $ 20 $ TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $ spill buckets, sumps, misc. $ 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 hc1:3-1_F 1�Z•;crY:IUky:[•111:dAI:L�1w11'I�:rt�i(y�a•�3�T `_ iI ►. • . , OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED; ECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 03/20/09)