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03/11/2006 TUE 7:40 FAX 2094`c3433 SJC EHD 0007/007 <br /> s <br /> v <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Te%phone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orzlehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> c )vtr- E--r / -lam 121c0 �t�s�GIT <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> �(.0 '4--lc CiR'YYl p 9 61 1 210 - S t 5 3 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> APPLICANT BILLING NAME EAPPLICAKTCONTACTTACT NAME ffflL-C - KG�APPLICANT MAILING ADDRESS NE#WITH AREA CODE <br /> Gon/ S70 •SCITY STATE ZIP CODERK TO BE DONE CONTRACTORICC#6o m,0NA '70197`1 on Repair Retrofit <br /> ACTIVE FACILITY <br /> 2003 2004 2005 2006 2007 2008 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <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 Permlltad CAmm in Place <br /> TANK ID# s CLOSURE FEE_$2941 TANK #TANKS X$294= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$294/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction lns Ctions <br /> TANK ID#(a): PLAN CHECK FEE_$784/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$294/FACILITY (use kr rtankodng eryuiNgmenL cold starts,EVR upgrades, <br /> spill buckets,sumps,mix. <br /> PIPING REPAIR FEE _$294/FACILITY use for piping.under-dispenser coMainmenL act.) <br /> MISCELLANEOUS <br /> TRANSFER FEE = 20 <br /> CONSULTATION FEE = E 981 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $96/HOUR <br /> SAMPLING INSPECTION FE = S 9E/HOUR <br /> ALL FEES ARE BASED ON THE$98 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 RECENED <br /> SR <br /> EH 23032(REVISED 11131107) <br />