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• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTHDEPARTrtl./ <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjeov.orPJehd <br /> FACILITY NAME I FACILITY CONTACT!AREA <br /> FACILITY ADDRESS SITE PHONE#WITH CODElieqqC) r ( <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> L.ad-h re CA ,s <br /> APPLICANT BILLING NAME I APPLICANT CONTACT NAME <br /> E Li,fc )v C0 trrr Cxr i e- / f,ts✓ <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> oZS35 rl02 DrtUC 4(A — (r33 <br /> CITY I STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> c(: C SJ-OT Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) 2002 2003 2004 2005 2006 2007 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008 8,New <br /> Installs as of 8/7/07) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> emoval or Permitted Closure in Place <br /> TANK ID#(a): CLOSURE FEE=$294/TANK #TANKS X$294= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins 'ons <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$294/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Ian Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$784/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANKID# s : <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY use for monitoring equipment,s ill buckets,tank sum ,misc. $�� <br /> PIPING REPAIR FEE _$294/FACILITY use forpiping,under-dispenser containment,actI $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $98r HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR $ <br /> SAMPLING INSPECTION FEE. - $9 <br /> EE _ $98/HOUR $ <br /> ALL FEES ARE BASED WON $98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECENED <br /> SR <br /> EH M 0321REVISED 09!3/971 <br />