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SAN JOAQUIN COUNTY <br />R ENVIRONMENTAL HEALTH DEPARTMEN$ <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjcehd.com <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />�G/ %G <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />FACILITY ADDRESS <br />2015 <br />SITE PHONE P WITH AREA 90DE <br />STATE <br />Loci <br />CIRCLE WORK TO BE DONE <br />CITY <br />STATE <br />ZIP CODE# <br />OF TANKS AT SITE <br />$130 PER TANK AFTER FIRST TANK <br />CA <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />CLOSURE FEE = $390 / TANK <br />2011 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2014 <br />2015 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s) : <br />CLOSURE FEE = $390 / TANK <br />2011 <br />2012 <br />2013 <br />2014 <br />2015 <br />2016 <br />$ <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK <br />$130 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place) <br />TANK ID # (s) : <br />CLOSURE FEE = $390 / TANK <br /># TANKS X $390 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $390 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Ir <br />TANK ID # (s) : I PLAN CHECK FEE = $1040 / FACILITY I $ I <br />REPAIR PLAN CHECK <br />TANK ID#(s): <br />$ <br />TANK RETROFIT REPAIR FEE = $390 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, misc.) <br />$ <br />SAMPLING INSPECTION FEE = $ 130/ HOUR <br />$ <br />PIPING REPAIR FEE = $390 / FACILITY (use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 130/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 130 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 130/ HOUR <br />$ <br />r GCO HRC GAOGU MY 1 nr .0 IJV rIV URL 1 RH 1 C. 1IMC 1 rIA 1 r-AI.CCUO rCCO YAIU VVILL CC CSILLCU I V AYYLIl.AN I . <br />TOTAL AMOUNT DUE $3� <br />OFFICE USE ONLY <br />SERVICE REQUEST # I FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 02-03-2016) <br />