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SAN JOAQUIN COUNTY <br /> 9EINTVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone, (209)468-3420 Foix; (209)468-3433 Web;www.sj og v.orp/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> // ew ✓' <br /> rA0LITY ADDRE / ,w 517E PHOWE#WITH AREA CODE <br /> ?22 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> G., <br /> CA2- <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#NTH_ AREA CODE <br /> � l 14 , <br /> CITY C„..(-0,A,rte 4V I STATE I ZIP CODE CLE WORK TO BE DONE CW-Mf§CTGR lCC <br /> i Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE.+1 TANK(2047.200$) 1 <br /> 2008 2009 2010 2011 2012 2013 <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2009-2012) <br /> $125 PER TANK AFTER FIRST TANK E $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.001 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 Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$3751 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s) : I PLAN CHECK FEE_$10001 FACILITY $ 61, vo <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =$375 1 FACILITY (use for monstor ng equipment,cord starts,EVR upgrades, $p Q-0 <br /> s ilI buckets,sumps,misc. <br /> PIPING REPAIR FEE =$375/FACILITY (use for piping,under-dispenser containment,ect $0.o-0 <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $125!HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $1251 HOUR $ <br /> SAMPLING INSPECTION FEE _ $1251 HOUR $ <br /> ALL FEES ARE BASED ON THE$126 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNTRECEW I RECEIVED BY I DATE RECEIVED <br /> I <br /> EH 23 022(REVISED 11161201$by KF) <br />