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s SAN JOAQUIN COUNTY <br /> L ENVIRONMENTAL HEALTHDEPARTME+rO' <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sj¢ov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 114T G© i.� G <br /> FACILITY ADDR SS SITE PHONE#WITH AREA CODE <br /> pZ15Y S. L of JU o 3 /�x/e hLci ti <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> S %oGAt;;Pa---,d CA 95;Z03 Lf <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> allo /01/ /�v/'-J L <br /> i;-- <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> -30 9 04'/ 000 C-- - 3 /�/ <br /> CITY STATE ZIP CODE CIRCLE RK TO BE DONE CONTRACTOR ICC# <br /> C • tetrofit <br /> ACTIVE FACILITY S12 66(o toj <br /> 06 2007 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2004-2007) 2004 2005 202008 2009 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2009) <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 /> PERMANENT CLOSURE vu <br /> Removal or Permitted Closure in Place <br /> TANKID# s CLOSURE FEE=$2�5/TANK #TANKSX.$ <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE_$315/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspectors) <br /> TANK ID#(s): PLAN CHECK FEE_$840/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(S): <br /> TANK RETROFIT REPAIR FEE =$315/FACILITYuse for monitoring $ <br /> ( g equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,mist. <br /> PIPING REPAIR FEE _$315/FACILITY use forpiping,under-dispenser containment,ect $ <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 FES BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> 107 LIU P1P�S4, 61 (1) UST petM . c.[01U'c— X306 9f �it-e <br /> OFFI E USE O Y <br /> SERVICE REQUEST#- FACILITY ID AMOUNT RECEIVED I CHECK 1 RECEIVED BY I DATE RECEIVED <br /> sR bb( 105-L- FA �D2bSl°I <br /> --ii M9lPFVIQGII ninnmz, <br />