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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTIVIENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:wwW.sj ov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> L7 S ht G ',✓. 6 p Q <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> N.E. (orn�rf/ '6w< 07 �/Y.�kefS74 SSY! y G37 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA Sa G <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> (SCO,-on Con re, an S Ro6-rf <br /> APPLICANT MAILING ADDRESS APPLICANT441E WITH AREA CODE <br /> G 9'70-Gs3s <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE I CONTRACTOR ICC# <br /> A'4 0 o u y1 Posur-e5 Installation Re air Retrofit <br /> ACTIVE FACILITY <br /> 2011 20 <br /> $500 FEE INCLUDES FACILITY FEE+i TANK(2007-2008) 2008 2009 2010 12 2013 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009-2012) <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=$35.00/FACILITY 1 $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> T'9- <br /> TANK ID#(s): CLOSURE FEE_$375/TANK #TANKS X$3}E= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$3751 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1000/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$3751 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE _$375/FACILITY (use for piping,under—dispenser containment,act.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $125/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $125/HOUR $ <br /> SAMPLING INSPECTION FEE = $125/HOUR $ <br /> ALL FEES ARE BASED ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNTRECEIVED CHECK# I RECEIVED BY I DATE RECEIVED <br /> EH 23 032(REVISED 1/16/2013 by KF) <br />