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SAN JOAQUIIN COUNTY <br /> • ENVIRONMENTAL HEALTH DEPARTMEIO <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sj og v.or ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> JPLEQo *%aAt <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> t" 6 K 0q 2 r ests <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> CA Q53�to I 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> kfAA�'�[ St ►cC� d-tC. MP49APe 1SELL) <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> •o • &x lDo-4 low, '61 op <br /> CITY STATEZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> 0\bLf � 1 Q401 g5020 Closure Installation Repai Retrofit S?i123�'�'ll'f <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2004-2007) <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 COPA PROGRAM=$49.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$345/TANK #TANKS X$345= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$345/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(a): PLAN CHECK FEE=$920/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$345/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc.) <br /> $ <br /> PIPING REPAIR FEE _$345/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $115/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $115/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $115/HOUR <br /> ALL FEES ARE BASED ON THE$115 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 RECEIVED <br /> SR <br /> EH 23 032(REVISED 07/01/09) <br />