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SAN JOAQUIN COUNTY AM <br /> ENVIRONMENTAL HEALTH DEPARTMI r <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fier.(209)468-3433 Web:www.sjgov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> F(rACILIADRbess SITE PHONE# TH AREA CODE <br /> CITY STATE ZIP CODE L I #OF TANKS AT SITE <br /> CA15,222 <br /> I5Z 5? <br /> APPLICANT BILLING NAMEI APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS I APPLICANT PHONE#WI AREA CODE <br /> CITY TCIRCLE STATE ZIP CODE WORK TO BE DONE CONTRACTOR ICC#Ci <br /> nstallation epai Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) 2003 2004 2005 2006 2007 2008 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK <br /> $125 PER TANK 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=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Per Closure in Place <br /> TANK ID# s CLOSURE FEE=$294/TANK #TANKS X$294= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ons <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$294/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$784/FACILITY $ <br /> [REPAIR PLAN CHECK <br /> ANK ID#(s)ANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets,sumps,misc.)Z <br /> PIPING REPAIR FEE _$294/FACILITY use for in ,under-dispenser containment,ect. $ <br /> F <br /> EOUS <br /> FEE _ $20 $ <br /> ION FEE _ $98/HOUR $ <br /> ZED RELEASE EVALUATION FEE _ $981 HOUR $ <br /> SAMPLING INSPECTION FEE = $98/HOUR $ <br /> ALL FEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT ES PAID EXCEEDS FE =MLLBE 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 12131107) <br />