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JAN-17-2006 06:53 SArvice Station Systems 408 938 8888 P.03i12 <br /> SAN JOAQUiN COUNTY <br /> ENT VIRONMENTAL HEALTH DEPARTMENT <br /> 304 East'Weber Avenue,3d FIoor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(SraJloor):(209)468-3433 Web:www.Sjeov.crg/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> [ 5S3 Cold, 41O I 3,S-q •- 0140 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> �l �aVl CA Qs � 3 <br /> APPLICANT BILLING NAME ' APPLICANT CONTACT NAME <br /> 5 r-voCe...34 0-ito�A 5i"CrvlS, ,y-rit�, N0.i" W&2 LtA-ICLo <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> (A0 Avg. g �l3- X003$ <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> $ate J��, C� 95�� ,Z.• Closure Installatio air <br /> e Retrofit <br /> ACTIVE FACILITY <br /> 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 2001 2002 2003 2004 2005 <br /> $125 PER TANK AFTER FIR$T TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE-$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24,001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure In Place <br /> TANK ID#(s); CLOSURE FEE-$279/TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$2791 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> TANK RETROFIT REPAIR FEE =$2791 FACILITY tyse for monitorin a ul ment,sell[buckets,tank sumps,misc, <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE = $93/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE $93/HOUR <br /> SAMPLING INSPECTION FEE = 5 93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL SE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY 10 AMOUNT RECEIVED CHECK A RECEIVED BY DATE RECEtVEA <br /> SR <br /> EH 23 032(REVISED 02127105) <br />