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• <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone. (209)468-3420 Fav(209)468-3433 Web:www.sjgov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> d, CA e-- <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 41 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#NTH AREA CODE <br /> '3 A,, �'tea- S ( 91,K) 7-3 cli-771cl <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> 6 7 Closure �stallafio Repa97:Fe7t:ro7ft� e-7—,e-7-07T' <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2004-2007) <br /> $550 FEE INCLUDES FACILITY FEE+I TANK(2008-2009) <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=$49.00/FACILITY <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$345/TANK #TANKS X$345 <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE $345 FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE $920 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$84</FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $3&6, <br /> spill buckets,sumps,misc.) <br /> PIPING REPAIR FEE =A34f/FACILITY use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE $20 <br /> CONSULTATION FEE $115/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE $115/HOUR <br /> SAMPLING INSPECTION FEE $115/HOUR <br /> ALL FEES ARE BASED ON THE$115 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 /> IR <br /> S � <br /> EH 23 032(REVISED 07101/09) <br />