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• REGiva1 <br /> SAN JOAQUIN COUNTY DEC 112015 <br /> ENVIRONMENTAL HEALTH DEPARTMENT ENVIRONMENTAL <br /> E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sicehd.com 1-1417*J nroaOTAOCKIT <br /> FACILITY NAME FACILITY CONTACT NAME <br /> i1��L At"1vp1- <br /> �oN gM1ovso� <br /> FACILITY ADDRESS SITE PHONEUy <br /> #WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> TD C X � CA GIS20 3 t <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 5PI-wai �T97ro�+ SYST►i ; ,/I'l'lA1t-K SNAW <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 6,66 Aul 9/(0 56�-z-538 <br /> CITY STATE ZtP CODE CIRCLE WORK TO BE DONECONTRACTOR ICC# <br /> N <br /> GA 1 Closure Installation Rea' Retrofit3ZS�33 <br /> ACTIVE FACILITY <br /> 2010 2011 2012 2013 2014 2015 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK <br /> $130 PER TANK AFTER FIRST TANK $ <br /> TANK PEN Ai TY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY'ON INVENTORY IN A CUPA PROGRAM=$35.00/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID#(a): CLOSURE FEE=$3901 TANK I #TANKS X$390= <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ectians $ <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$390/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections $ <br /> TANK ID#(a): PLAN CHECK FEE=$10401 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK RETROFIT REPAIR FEE _$390/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 3gp <br /> S ill buckets,sum s,misc.) $ <br /> PIPING REPAIR FEE=$390/FACILITY use for i in ,under-dispenser containment,eGL <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $25 <br /> $ <br /> CONSULTATION FEE _ $130/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $1301 HOUR $ <br /> $ <br /> SAMPLING INSPECTION FEE _ $130!HOUR <br /> FEES ARE BASED ON THE E130 HOURLY RATE. TIME THA71 EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $$SS. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUN (,RECEIVED CHECK# RECENED BY DATE REGENED <br /> EH 23 032(REVISED 04-22-05) <br />