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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT \0 <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(54floor):(209)468-3433 Web:www.sigov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> S£-Ql-up- So v �vr> cru bc� L� fn <br /> FACILITYADD SITE PHONE#WITH AREA CODE <br /> aHa `$wd- po 4& l <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> aocv_{ CA gSaoµ <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 3-(yV 1`CmSfD-k(>ti S <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> (Dfi-O QUiVLo A-v.e, ,lbk .21 a - 4o V <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> sa-L - CAG I a,,, Closure Qnstallation Repair Retrofit 5.?sQ�Z.�... U l <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 2000 2001 2002 2003 2004 2005 <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 /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE_$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Canstruction Ins ections <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID# s : y <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY use for monitoring equipment,s ill buckets,tank sumps,mist. $ <br /> PIPING REPAIR FEE _$2791 FACILITY use for piping,under-0is eraser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $93/HOUR $ - <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $931 HOUR $ <br /> SAMPLING INSPECTION FEE = $93/HOUR $ <br /> ALL FEES ARE BASED ON THE$93 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# I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED Ot122/05) <br />