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SAN JOAQUIN COUNTY <br />NVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.or /g ehd <br />FACILITY NAME <br />TANK ID # (s) : <br />FACILITY CONTACT NAME <br />2002 <br />/ <br />2004 <br />FACILITY ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />SITE PHONE # WITH AREA CODE <br />r <br />1 <br />) <br />CITY <br />STATE <br />STATE <br />ZIP CODEf <br />F TANKS AT SITE <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />CA <br />Closure Installation ERbRetrofit <br />APPLICANT BILLING NAME <br />TANK ID # (s) : <br />A ICANT CONTACT NAME <br />2002 <br />/ <br />2004 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />4 <br />® <br />` / . <br />CITY <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />Closure Installation ERbRetrofit <br />ACTIVE FACILITY <br />TANK ID # (s) : <br />CLOSURE FEE = $294 / TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />1 <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 />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />(Removal or Permitted Closure in Place <br />TANK ID # (s) : <br />CLOSURE FEE = $294 / TANK <br /># TANKS X $294 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $2941 FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />I <br />PIPING REPAIR FEE = $294 / FACILITY (use for piping, under -dispenser containment, ect.) <br />TANK ID # (s) : <br />PLAN CHECK FEE = $784 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <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 />I'm <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 98/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />SAMPLING INSPECTION FEE _ $ 98/ HOUR <br />ALL FEES ARE BASED ON THE $98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST 11 LILITY ID AMOUNT RECEIVED CHECK It I RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 /REVISED 06/3/071 <br />