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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPAR <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> r <br /> FACT AD RESS SITE PHONE# TH AREA CODE^ <br /> cSlUt� <br /> CITY S I ZIP CODE #OF TANKS AT SITE <br /> CA JZ <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Mi <br /> APPLICANT MAILING ADDRESS I APPLICANT PHONE#WI AREA CODE <br /> r <br /> m <br /> CITY STATE ZIP CODE IRCLE RK TO BE DONE CONTRACTOR ICC# <br /> (� Closure Installation 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 Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$294/TANK #TANKS X$294= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ctions <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$294/FACILITY $ <br /> INSTALLATION PIAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$784/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets,sumps,misc. Z <br /> PIPING ci� <br /> REPAIR FEE _$294/FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE—= $98/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $98/HOUR $ <br /> SAMPLING INSPECTION FEE _ $98/HOUR $ <br /> ALL FEES ARE BASED ON THE$99 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 12/31/07) <br />