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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.sj o>? v.or /g ehd <br />NAME <br />CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />Closure 'Installation Repair Retrofit <br />ACTIVE FACILITY <br />La8 <br />INCLUDES FACILITY FEE + 1 TANK (2002-2007) 2002 2003 2004 2005 2006 2007 <br />INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />of 8/1/07) $ <br />TANK AFTER FIRST TANK <br />ALTY ASSESSED $ <br />CHARGE = $15 / TANK $ <br />CHARGE 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 />_TEMPORARY CLOSURE <br />CLOSURE FEE = $294 / TANK <br /># TANKS X $294 = $ <br />(Plan Review and Inspections) <br />TANK ID # (s) : :::::]TEMPORARY <br />CLOSURE FEE _ $294 / FACILITY $ <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <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 bucketsEtank umps, misc.) $ <br />PIPING REPAIR FEE = $294 / FACILITY <br />(use for Dioina_ undar-rlicnancar P—I+ ir,r., f --f , $ <br />TRANSFER FEE = $ 20 $ <br />CONSULTATION FEE = $ 98/ HOUR $ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 98 / HOUR $ <br />SAMPLING INSPECTION FEE _ $ 981 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# FACILITY ID I AMOUNT RECEIVED vcu I l.tYtGK #DATE RY I Hort ocnr <br />SIR � i <br />EH 23 032 (REVISED 0813/071 <br />