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11 <br />rI <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www,sigov.org/ehd <br />FILITY AME <br />TANK ID # (s): <br />FACILITY CONTACT NAME <br />f/M/ <br />2009 <br />CIN <br />FACILITY ADDRESS <br />ZIP CODECIRCLE WORK TO BE DO <br />SITE PHONE # WITH AREA CODE _» <br />41q� <br />CITY <br />STATE <br />Z CODE # OF TANKS AT SITE <br />UNAUTHORIZED RELEASE EVALUATION FEE = $125 / HOUR <br />CA <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />TANK ID # (s): <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />2008 <br />2009 <br />CIN <br />SAE <br />ZIP CODECIRCLE WORK TO BE DO <br />CONTRACTOR ICC # <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) <br />Closure Installation ffe air t <br />UNAUTHORIZED RELEASE EVALUATION FEE = $125 / HOUR <br />a 2016 <br />h} � T ��I•f�r; g <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br />2008 <br />2009 <br />2010 <br />2011 <br />2012 <br />2013 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 125/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 /TANK <br />J. <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br /># TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />INSTALLATION PLAN CHEC <br />(Plan Check and Construction <br />TANK ID # (s) : <br />PLAN CHECK FEE = $1000 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$Ntr <br />soil[ buckets, sumps, misc.)p <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />PtP1fd FE — - <br />$ <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 125/ HOUR <br />ALL rtt5 AKt UASCU UN I rit 472011UV KLT MAI c. I unc —A i cn�.ccv� � a. a..a . r,,.+ ..,•-,. .+...•,... • .. •�• •-•.-• •• <br />TOTAL AMOUNT DUE <br />