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` SAN JAQUIN COUNTY <br /> ENYIRONME. 'AL'HPALTH DEPARTMEI <br /> 30 ast Weber Avenue,3"Floor,Stockton,CA 9502-2708 <br /> Telephone.(209)468-3420 Fax(5"floor):(209)468-3433 Web:www.sigov_org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Cc CA-my " ,-e_. ,Que titev�% o <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 2Ho18 f, MP)TJ V-, 2001 U73 - 226 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> S LL17'j CA 1 ClSZ04 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2001 2002 2003 2004 2005 2006 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 75-6 <br /> 7! I! <br /> $125 PER TANK AFTER FIRST TANK <br /> -150 <br /> 750 7S{{0 790 7,5V —/7 rJ U $-1 5-00 <br /> TANK PENALTY ASSESSED 7d5� 7�'o JO 9'0 7S0 ! JO $4 Sob <br /> TANK SURCHARGE=$15/TANK $ yS <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ 2 <br /> Lf <br /> PERMANENT CLOSURE Zvi 061 , 06 <br /> Removal or Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$285/TANK #TANKS X$285= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$285/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$760/FACILITY <br /> REPAIR PLAN CHECK <br /> TANKID# s : <br /> $ <br /> TANK RETROFIT REPAIR FEE =$285/FACILITY use for monitoring equipment,s ill buckets,tank sumps,misc. <br /> $ <br /> PIPING REPAIR FEE _$285/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $95/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $95/HOUR <br /> SAMPLING INSPECTION FEE _ $95/HOUR <br /> ALL FEES ARE BASED ON THE$95 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID = AMOUNT RECEIVED I CHECK# RECEIVED BY DATE RECEIVED <br /> SR ( 5-1011 <br /> EH 23 032(REVISED 01/29107) <br />