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l <br />• SAN JOAQUIN COUNTY <br />Emv.RON? RENTAL HEALTH DEPART* <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj og v_org/ehd <br />FACILITY NAME <br />APPLICANT <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />2002 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />FACILITY ADDRESS <br />- <br />SITE PHONE # WITH ARE CODE <br />STATE <br />I ZIP CODE <br />f�_ <br />fAT <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS SITE <br />TANK PENALTY ASSESSED <br />CA eA <br />52 <br />95212 - <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />Installs as of 8/1/07) <br />$125 PER TANK AFTER FIRST TANK <br />2002 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />D <br />- <br />CITY <br />STATE <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />9bClosure <br />Installation Repair Retrofit <br />TANK PENALTY ASSESSED <br />ACTIVE FACILITY <br />TANK ID # (s): CLOSURE FEE = $294 / TANK # TANKS X $294 = <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />Installs as of 8/1/07) <br />$125 PER TANK AFTER FIRST TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />$ <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 =$24.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): CLOSURE FEE = $294 / TANK # TANKS X $294 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />and Construction <br />TANK ID # (s) : <br />PLAN CHECK FEE = $784 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />$ <br />PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 98/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 98/ HOUR <br />ALL FEES ARE BASED ON THE !tqa urn Iai v ca erc Tmfic T <br />$ <br />HAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br /># <br />SERVICE REQUEST FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 08/31071 <br />