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SAN JOAQUIN COUNTY WOOO, <br /> {OAY� <br /> ENVIRONMENTAL HEALTH DEPARTMENT . <br /> RECSrV <br /> 600 East Main Street,Stockton,CA 95202-3029 � <br /> Telephone:(209)468-3420 Faze(209)468-3433 Web:www sieov or /n ehd DEC, <br /> FACILITY NAMEOAN <br /> FACILITY CONTACT NAME O LUU� <br /> ENV�OUIN OUNTV <br /> / FACILITY ADDRESS SITE PHONE#WITH AREA CODE H M NT <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE if WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC If <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2003 2004 2005 2006 2007 2008 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) �� <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) $ sS.J <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=$24.00/FACILITY <br /> PERMANENTCLOSURE 9G ��Or <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$315/TANK #TANKSX$315= <br /> TEMPORARY CLOSURE �� 4,1� <br /> Plan Review and Inspections) <br /> moi- <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$315/FACILITYtj <br /> 'v <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins actions <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE=$8401 FACILITY O <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK RETROFIT REPAIR FEE _$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sum s,mist. <br /> $ <br /> PIPING REPAIR FEE _$315/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = $105/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1051 HOUR <br /> $ <br /> SAMPLING INSPECTION FEE = $105/HOUR <br /> ALL FEES ARE BASED ON THE 5105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I I RECEIVED BY DATE RECEIVED <br /> SR 061 1: I.30 1DD'7, -- ? o $ t2—/j2JD5r <br />