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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.slgov.or /e�hd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> /GL <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CO E <br /> S5 x �r 9y� - 9- S <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> DC�,'lo CA 95':2-/ S 13 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ) r�A <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE-#WITH AREA CODE <br /> X8 5s- S - "� 9 y ye -Zy3 ? <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE I CONTRACTOR ICC# <br /> GcAi `f'S2J S Closure Installation Repai Retrofit <br /> ACTIVE FACILITY <br /> 2005 2006 2007 2008 2009 2010 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2005-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2010) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$15/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID# s CLOSURE FEE=$366/TANK #TANKS X$366= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$366/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE=$976/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): r <br /> TANK RETROFIT REPAIR FEE =$366/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ N <br /> spill buckets,sumps,MISC.)-1 <br /> $ <br /> PIPING REPAIR FEE _$366/FACILITY use for piping,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $25 <br /> $ <br /> CONSULTATION FEE _ $122/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $122/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE = $122/HOUR <br /> ALL FEES ARE BASED ON THE$122 HOURLY RATE. TIME THAT E%LEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED T CHECK# I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07121/10) <br />