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• SAN JOAQUIN COUNTY i <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone.(209)468-3420 Fax:(209)468-3433 Web:w .sjgov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> LGcV-F-FogzO s4m <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 14oco E . 88 IcR -72-7- 541-Z <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> t OGCIE�70CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> wkiME SU20WES C-11e e,\--7 bV'%aS <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> ZSl9 'LCsVL� �� 46e 8`70- <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> W . SAC-4MtVIb CA 95q,l ClosureInstallati etr SZ 38-772. <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) $ <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 <br /> Removal or Permitted Closure in Place <br /> TANK ID# 5 CLOSURE FEE=$294/TANK #TANKSX$294= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$294/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$784/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> $ <br /> PIPING REPAIR FEE _$294/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $98/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $981 HOUR <br /> SAMPLING INSPECTION FEE _ $98/HOUR <br /> ALL FEES ARE BASED ON THE$98 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 12131107) <br />