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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.sjeov.orPJehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> C�t`t s k NIAwTIc rY: ot'I c kl?v <br /> FACILITY ADDRESS t SITE PHONE#WITH AREA CODE <br /> V <br /> CITYI STATE ZIP CODE #OF TANKS AT SITE <br /> wlTg CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> C; O ' z c l <br /> APPLICAN MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 1 . � ' -�� <br /> CITY STATE ZIP CODE CI CLE WORK TO BE DONE CONTRACTOR ICC# <br /> CII, f Closure Installation Repair Retrofit Z�Q� <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2005-2007) 2005 2006 2007 2008 2009 2010 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2010) <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=$49.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$366/TANK #TANKS X$366= $3(.(o <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE_$366/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$976/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$366/FACILITYmonitodn equipment,use for cold starts,EVR u $ <br /> ( g ment,q p upgrades, <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE _$366/FACILITY use for piping,under-dispenser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $122/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $122/HOUR $ <br /> SAMPLING INSPECTION FEE = $1221 HOUR $ <br /> ALL FEES ARE BASED ON THE$122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR 031e O <br /> EH 23 032(REVISED 07/21/10) <br />