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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />a o1I <br />a <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />a <br />j <br />CITY <br />STATE ZIPCODE # OF TANKS AT SITE <br />I ZIP CODE <br />CA ,��L- / <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />�v1 'i"0'W�G�� <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />'bftp-5 Gt i1 <br />'//�5'Z2 <br />CITY <br />STATE <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE I CONTRACTO77d <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />Closure Installation Rep air Retrofit <br />ACTIVE FACILITY <br />TANK ID # s <br />CLOSURE FEE = $375 / TANK <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />2012 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ed. <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $125/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM =$49.00/ FACILITY <br />PER ENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # s <br />CLOSURE FEE = $375 / TANK <br /># TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and 1 ons <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />kl-LATION PLAN CHEC <br />Check and Construction <br />TANK ID # (s) : I PLAN CHECK FEE = $1000 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TRANSFER FEE _ $ 25 <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />ill buckets, sumps, misc. <br />CONSULTATION FEE = $ 125/ HOUR <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ed. <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $125/ HOUR <br />ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED To APPLICANT. <br />TOTAL AMOUNT DUE $ <br />