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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.sjgov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />CA*At&"'AVj&� <br />�[t11A1 <br />FACILITY ADDRESS,,„„� <br />SITE PHONE # WITH AREA CODE <br />g_ <br />�PHONE y## <br />5 ((0 <br />CITY <br />STATE <br />ZIP CODE # OF TANKS AT SITE <br />CONTRACTOR ICC # <br />CA <br />OLS✓`% 0-5 CD <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />051 0-w 1i 11 L �. <br />_ <br />eAi�. liV i 0^/ <br />APPLICANT M/jA,I/L'ING�fADDR <br />APPLICANT WITjH. AREA CODE <br />1 4�® ?cAf t., , p <br />�PHONE y## <br />5 ((0 <br />CITY <br />STATE ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br /><C1—o,—,'r-ja5 Installation Repair Retrofit <br />ACTIVE FACILITY <br />Permitted Closure in Place <br />t°(e( —[CLOSURE <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) <br />$ <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 =$49.00/ FACILITY <br />PERMANENT CLOSURE <br />Permitted Closure in Place <br />t°(e( —[CLOSURE <br />$ <br />$ <br />TANK ID # s : <br />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 />PLAN CHECK <br />TANK ID # <br />PLAN CHECK FEE = $1,000 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />$ <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />spill buckets, sumps, misc. <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />$ <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, act. <br />MISCELLANEOUS <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 />$ <br />ma. rcca wce oi4ocu ury THE ;pi25 HOURLi RA E. TIME t HAI EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE $ i-1 <br />