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SAN JOAQUIN COUNTY - _ <br />AlkENVIRONMENTAL HEALTH DEPARTMENT <br />0 East Maim Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjov or /� ehd <br />ou 1 <br />FACILITY, NAME <br />FACILITY CONTACT NAME <br />APPLICANT CONTACT <br />EUSE, a <br />FACILITY ADDRESS <br />SITE PH E #WITH AREA CODE <br />APPLICANT MAILING <br />On 3 t4 <br />CITY $TATE <br />ZIP CODE # OF TANKS AT SITE <br />�r:-ter; <br />CA <br />CITY <br />STATE <br />APPLICANT BILLIN <br />'NAME' <br />APPLICANT CONTACT <br />EUSE, a <br />TANK ID # (s): <br />TEMPORARY CLOSURE FEE _ $3751 FACILITY <br />APPLICANT MAILING <br />ADDRESS <br />APPLICANT PHONE #WIT idREA CODE <br />�r:-ter; <br />If <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE`WORK OB 4yNE <br />CONTRACTOR ICC # <br />i <br />Closure Installation al, Retrofit <br />PERMANENT CLOS�I,RE III Removal or Permitte Closure iri Place <br />TANK ID # s CLOSURE FEE _ $375 / TANK # ANKS X $375 = <br />TEMPORARY CLOS RE <br />Pian Review'and Ins ectidns <br />TANK ID # (s): <br />TEMPORARY CLOSURE FEE _ $3751 FACILITY <br />PLAN CHE( <br />/ FACILITY I - __.__- . <br />REPAIR PLAN CHECK <br />TANK ID # (s) <br />TANK RETROFIT REPAIR FEE _ $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />---spill , buckets, sum s, misc. <br />PIPING REPAIR FEE = $375 / FACILITY <br />use for i in , under dis enser containment, act. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />CONSULTATION FEE- _ $ 125/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 125 /HOUR <br />SAMPLING INSPECTION FEE _ $ 125/ HOUR <br />ALL-FEESARE BASED ON THE -$125 HOURLY RATE-. TIME -THAT EXCEEDS PEE <br />TOTAL AMOUNT DUE <br />