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sft.f SAN JOAQUIN COUNTY %W10 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.s'gov.or#/chd <br /> FACILITY NAME y� FACILITY CONTACT NAME <br /> Y'a C Y j�c�Yc�w N S, vL <br /> FACILITY RESS SITE PHONE#WITH AREA CODE <br /> 3`1o0 Y-ivq Al-k- "A l 90 <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> TYct CA Cef CKV7 6 <br /> APPLICANT BILLI NAME APPLICANT CONTACT NAME <br /> -TYc� -Y t Kr- • [-�GYarn I S( H - t . <br /> APPLICAN AILING ADDRESS /1 APPLICANT PHONE#WITH ARE CODE <br /> '3 0(a N 1(e-i0�nvlAvv o <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Y C `C376 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) 2003 2004 2005 2006 2007 1 2008 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) <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#(a): CLOSURE FEE=$315/TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$315/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$840/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets,sumps,misc.)$� `1 <br /> PIPING REPAIR FEE _$315/FACILITY use for piping,under-dispenser containment,act.) 7�5 W <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $105/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $105/HOUR $ <br /> SAMPLING INSPECTION FEE = $105/HOUR $ <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATE RECENED <br /> SR <br /> EH 23 032(REVISED 7/18/08) <br />