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• SAN JOAQUIN COUNTY • <br /> ENvmomiHN'TAL HEALTH DEPARniErNT <br /> 1365 E.Hazelton Ave-Stock-ton,CA 95 205-623 2 <br /> Tr1rpLonr:(209)468-3420 Fav:(209)568-3433 TiiG:��'«Zvsj,oc.ols!ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Vaw/o Corw staYc 3(�4$ <br /> FACILITY ADDRESS SITE PHONE R WITH AREA CODE <br /> 153 E, 1( sera(- 20a ) 163 2 - 6(5i <br /> CITY STATE ZIP CODE fl OF TANKS AT SITE <br /> CA c�Sg b 3 <br /> APPLICANT BILLIING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE A WITH AREA CODE <br /> 2sbo Ave- #Mz- 031 (-t- �)1Lu til los <br /> CITYSTATE ZIP CODE CIRCLE WORK TO BE DONECONTRACTOR ICC R <br /> Closure Installation Repair ofi <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2007-2008) 2008 2009 2010 2011 2012 2013 <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2009-2012) <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=$35.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$3751 TANK #TANKS X$375= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1000/FACILITY I $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$375/FACILIT (usefor monitoring equipment,cold starts,EVR upgrades, $r�ZL+OD <br /> spill buckets,sumps,misc.)�•.Jl�7 <br /> PIPING REPAIR FEE _$375/FACILITY (use for piping,under-dispenser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $125/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $125/HOUR $ <br /> SAMPLING INSPECTION FEE = $125/HOUR $ <br /> ALL FEES ARE BASED ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE 1 $3x­b1 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST= I FACILITY ID I AMOUNTRECEIVED CHECK= J RECEIVED BY DATE RECEIVED <br /> I <br /> EH 23032(REVISED 1'16:2013 by KF) <br />