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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTME . <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.orvJehd <br />^•�I <br />APPLICANT CONTACT NAME <br />CcX��l►(�1 <br />W <br />APPLICANT MAILING ADDRESS <br />I APPLICANT PHONE # WITH AREA CODE <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 125 /HOUR <br />$ <br />CITY STATE <br />ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />Closure Installation a r Retrofit <br />' <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) 2006 2007 2008 2009 2010 2011 <br />$550 FEE INCLUDES FACILITY FEE + 9 TANK (2008-2011) <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />Removal or Permitted Closure in <br />TANK ID # (s) : <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Ins{ <br />TANK ID # (s) : <br />ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY I $ <br />CLOSURE FEE = $375 / TANK #TANKS X $375 = $ <br />TEMPORARY CLOSURE FEE = $375 / FACILITY $ <br />CHECK FEE = $1,000 / <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />—ill buckets, sum s, mist. <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect.) <br />$ <br />-MISCELLANEOUS __ .----- <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />Is <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 125 /HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 125/ HOUR <br />ALL FEES ARE BASED ON THE $125 HOURLY RATE "- <br />$ <br />FEES HAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE $ <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID I AMOUNT RECEIVED I CHECK # RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 08/1/11 by KF) <br />