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%./ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT ltll IIJI LLLMM <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sizov.org/chd SEP 1 6 2008 <br /> FACILITY NAME FACILITY CONTACT NAME ENVIACINNIPNIT iEALTH <br /> Ci ble- R Cit G PER JEIT/SER ICES <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1070 rv4 ' (z0f 45f-4i10' <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> /-A4kap ICA G+4 9rS330 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> kc 'S 6{LVj' ..!' 1-A!�� (fJ0Rf a1 pr <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH EA CODE <br /> 527 N• rkU igL, 7sr ) q'eq— 1730 <br /> CITY STATE I ZIP CODE CIRCLE WORK T _LRONE CONTRACTOR ICC# <br /> C6q ?37 Z&- Closure Installalio Repa etrofil 7-7110 <br /> (4 T <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) 2003 2004 2005 2006 2007 2008 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) <br /> $125 PER TANK AFTER FIRST TANK $ (, <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$iSITANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.001 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE=$315/TANK #TANKS X$315= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$315/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(a): PLAN CHECK FEE_$840/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE _$315/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $105/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $105/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $105/HOUR <br /> ALL FEES ARE BASED ON THE$106 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 I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 7/18108) <br />