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rte/ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(Sr"Jloor):(209)468-3433 Web.www.sjeov.orlJehd <br /> FACILITY NAME p FACILITY CONTACT NAME <br /> Lajo k k A��J S��d L k(}LCkaOo ecm,*t l(O� c)Gkgr.1 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 3rn1 W . p*�rAj NdVC '4S 4l - 1-103 <br /> CITY 1 STATE LP CODE I #OF TANKS AT SITE <br /> ST o cv-T aJ I CA cis-.1-1 VLK)P- Ax <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> G;L6 0 E . s<+X�(4 -tq -t f(-70 <br /> CITY STATE 21P CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> UcrvC SI CA eiYc Closure Installatio Repair Retrofit 52S05QF-t.4 I <br /> ACTIVE FACILITY <br /> 2000 2001 2002 2003 2004 2005 <br /> $500 FEE INCLUDES FACILITY FEE+t TANK <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE_$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$279/TANK #TANKS X$279= <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY use for monitoring equipment,s III buckets,tank sumps,mist. <br /> PIPING REPAIR FEE _$279/FACILITY use for piping.under-dispenser wntalnmen[,ec[. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $93/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR <br /> SAMPLING INSPECTION FEE _ $93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED I CHECK# I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02/22/06) <br />