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�../ SAN JOAQUIN COUNTY *-W� Ilvv��/1�� <br /> ENVIRONMENTAL HEALTH DEPARTMENT (1 (c, <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202-2708 L L%' <br /> Telephone:(209)468-3420 Fax(54'floor):(209)468-3433 Web:www.s*gov.org/chd JAN 2 <br /> FACILITY NAME FACILITY CONTACT NAME4ip Z��/ <br /> Che✓r c n f�47 o r-& nom- sin k� NEN HEA <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE p LTH�(EA <br /> 3/•00 rneL,-i4r4A w- bE'f*W y09 p3 <br /> CITYSTATE ZIP CODE #OF TANKS AT SITE <br /> Cy I CA C/ S-3 7 (o <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAM <br /> 'e r7 l�,lrcleur� /, Ieen DtS <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> I76 itAlemIkt 94rQe-f- �ZS)q&Z —Yo40 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation epa' Retrofit <br /> ACTIVE FACILITY <br /> 2001 2002 2003 2004 2005 2006 <br /> $500 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 /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$285/TANK #TANKS X$285= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE_$285/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$760/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$285/FACILITY use for monitoring equipment,s ill buckets,tank sumps,misc. $ V <br /> $ <br /> PIPING REPAIR FEE _$285/FACILITY use for piping,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $95/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $951 HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $95/HOUR <br /> ALL FEES ARE BASED ON THE$95 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE RE I AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07/28/08) <br />