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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.sjRov.org/ehd <br />v.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />1A k M c �-- S <br />(A -N5'5 <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />��? ►s 11 1 <br />L -Cu -(1 3 U <br />CITY STATE <br />ZIP CODE <br />I # OF TANKS AT SITE <br />CA <br />ei <br />Closure InstallationRepair Retrofit <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />(.... C_ Se -'r viC°e-5 <br />CU <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />��? ►s 11 1 <br />L -Cu -(1 3 U <br />CITY <br />STATE I ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />PIPING REPAIR FEE = $366 / FACILITY (use for piping, under -dispenser containment, ect. <br />4' �j <br />Closure InstallationRepair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $366 / TANK <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2005-2007) <br />PIPING REPAIR FEE = $366 / FACILITY (use for piping, under -dispenser containment, ect. <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 122 / HOUR <br />SAMPLING INSPECTION FEE _ $ 122/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2010) <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 CUPA PROGRAM =$49.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $366 / TANK <br /># TANKS X $366 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE= $366 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TANK RETROFIT REPAIR FEE = $366 / FACILITY (use for monitoring equipment. cold st , EVR upgrades, <br />spill buckets, sum s, misc. <br />CONSULTATION FEE _ $ 122/ HOUR <br />PIPING REPAIR FEE = $366 / FACILITY (use for piping, under -dispenser containment, ect. <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 122 / HOUR <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />CONSULTATION FEE _ $ 122/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 122 / HOUR <br />SAMPLING INSPECTION FEE _ $ 122/ HOUR <br />ALL FEES ARE BASED ON THE $122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED 1U APPLIGAN I. <br />