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CITY <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fay (209) 468-3433 Web: www.sigov.org/ehd <br />FACILITY CONTACT NAME <br />J <br />SITE PHONE # WITH AREA CODE <br />STATE ZIP CODE # OF TANKS AT SITE <br />CA / \ /' <br />- A I CkJ I \ <br />CITY STATE ZJP CODE CIRCLE WORK TO BE DONE CONTRACTOR <br />O 5 Closure -Installation eparr etrofit <br />ICC # <br />ACTIVE FACILITY <br />2005 2006 2007 2008 2009 <br />1!��1,2010.. <br />NCLUDES FACILITY FEE + Y TANK (2005-2007) <br />NCLUDES_EACI_L.I n -EEE+ 1- ANK (200&20x0) _ <br />-- - ---- <br />- <br />TANK AFTER FIRST TANK <br />tTANK <br />- - - — <br />4 <br />ALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15/TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />NENT CLOSURE <br />l or Permitted Closure in Place# <br />s CLOSURE FEE= $366!TANK #TANKSX$366= <br />F <br />ARY CLOSURE <br />view and In tions# <br />(s) : TEMPORARY CLOSURE FEE _ $3661 FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />- — -- - _ -- <br />) PLAN-CRECK-FEE = $9767FACILiTY <br />REPAIR PLAN CHECK <br />TANK ID # (s) <br />-.._ <br />jANK_RECROFIT,REPAIR-FEE.=.$3661 FACILITY.=(use for monitoring equipment cotdstarts, EVR-upgrades,. <br />-- <br />spill buckets, sumps, misc. <br />$ <br />`PIPING -REPAIR FEE' _ $366 / FACILITY use for piping, under -dispenser containment, ect. <br />[MISCELLANEOUS - 7 <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE _ $ 122/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE =$122/HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $122/ HOUR <br />ALL FEES ARE BASED ON THE $122 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 I DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 07/21/10) <br />