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09/09/2009 WED 11: 04 FAX 2094683433 SJC EHD --- Stockton Sexv Sta Eq Cc ®008/008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjeov.%Rlehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 6 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA ODE <br /> Sc*— <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT DMSYNG NAME APPLICANT CONTACT NAME <br /> CC <br /> APPLI ANT AILI G DDR SS CANT PHONE#WITH AREA CODE <br /> sos e�. w s 45 <br /> CITY STATE �ZIIPP,CnODE CIRCLE RK TO BE DONE CONTRACTOR ICC# <br /> �' Q>7 Closure Installation Repa' etrogt <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE-1 TANK(2004.2007) 2004 2005 2006 2007 2006 2009 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2000-2009) $ <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=$49.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$345/TANK #TANKS X$345= $ <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$345/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$920/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID Is(s): <br /> TANK RETROFIT REPAIR FEE =$345/FACILITY (use for moniloMg equipment,wild starts,EVR upgrades, �[ ee <br /> s dl buckets sumps,misc. <br /> PIPING REPAIR FEE _$345/FACILITY use for piping.under-dispenser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $1151 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $115/HOUR $ <br /> SAMPLING INSPECTION FEE = $115/HOUR $ <br /> ALL FEES ARE BASED ON THE$116 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED CHECKY I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07/01109) <br />