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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.sigov.or /� ehd <br />FACILITY NAME FACILITY CONTACT NAME <br />r <br />FACILITY ADDRESS SI P ONE # WITH AREA DE <br />1 <br />CITY IISTATE ZIP COUE <br /># OF TANKS AT SITE <br />ICA 3 C� <br />I ZIP CODE CIRCLE WORK T013E DONE CONTRACTOR ICC # <br />APPLICANT BILLING NAME <br />LICANT CONTACT NAME <br />APPLIC <br />APPLICANT P ON # WITH AREA CO E <br />2535 Wigwam Dr. <br />2006 <br />CITY Stockton, CA 9f, <br />I ZIP CODE CIRCLE WORK T013E DONE CONTRACTOR ICC # <br />2009 <br />Closure Installation RepaC Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $345 / TANK <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 115/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $345 / TANK <br /># TANKS X $345 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $345 / FACILITY <br />%LLATION PLAN CHECK <br />Check and Construction Ir <br />TANK ID # <br />PLAN CHECK FEE = $920 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TANK RETROFIT REPAIR FEE = $345 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, misc. <br />PIPING REPAIR FEE = $345 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 115/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 115/ HOUR <br />ALL FEES ARE BASED ON THE $115 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 07/01/09) <br />