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SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL I II:A1:1'I I DI:PARTMEN'I <br /> 600 fast Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 l�1r:(209)4C>8-3433 Web:www.sj<.ov_.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 15 l <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA 015 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADEFRYSS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> 1,,f Closure installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <br /> $500 FEE INCLUDES FACIL.I IY FEE+ 1 TANK(2004-2007) <br /> $550 FEE!.NCLUDES FACILITY FEE+ 1 TANK(2008.2009) <br /> $125 PFR-'ANK AFTER FIRST TANK <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 cr Permitted Closure in Place__ -- -- <br /> TANK ID#(s): CLOSURE FEE=$345/1 ANK #TANKS X$345= _ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID r(s): TEMPORARY CLOSURE FEE=$345/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction <br /> TANK ID;: (s): PLAN CHECK FEE=$920/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$345/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, yl <br /> spill buckets,sumps,mise) <br /> PIPING REPAIR FEE _$345/FACILITY (use for ping,under-dispenser containment,ect.) _— <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20..___. <br /> CONSULTATION FEF _ $115/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $115/HOUR________._ <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 07101109) <br />