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SAN JOAQUIN COUNTY EwiRONNIENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd FACILITY NAME FACILITY CONTACT NAME CLOSURE FEE = $375 / TANK 2006 FACILITY ADDRESS SITE PHONE # WITH AREA CODE 2009 2010 CITY STATE ZIP CODE # OF TANKS AT SITE &x0 CA7 Ga S-",?—% Z— APPLICANT BILLING NAME APPLICANT CONTACT NAME CLOSURE FEE = $375 / TANK 2006 APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2009 2010 CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # c, G rl 15 Closure Installation a air Retrofit 1 S ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $375 / TANK 2006 2007 2008 2009 2010 2011 $ $500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) $ PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) $550 FEE INCLUDES FACILITY FEE+ 1 TANK (2008-2011) $ $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $15 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $375 / TANK # TANKS X $375 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE= $375 /FACILITY ION PLAN CHEC and Construction ITANK ID # (s) : I PLAN CHECK FEE = $1,000 / FACILITY I $ I REPAIR PLAN CHECK TANK ID#(s): $ CONSULTATION FEE = $ 125/ HOUR $ TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $ spill buckets, sumps, misc. $ $ PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) MISCELLANEOUS TRANSFER FEE _ $ 25 $ CONSULTATION FEE = $ 125/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR $ SAMPLING INSPECTION FEE = $ 125/ HOUR $ ALL Fees ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. TOTAL AMOUNT DUE Is