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1" SAN TOAQUINCOUNTY <br /> EwRoNMENTAT,HEALTH DEPARTMENT <br /> 304 East Webcr Avenue,3"Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 F=(r jloor):(209)468-3433 Web:www.sieov.ora/ebd <br /> FACILITY <br /> CCN�,AIM�E�� FACILITY CONTACT NAME <br /> CGTC�o-{Jly <br /> FACILITY ADDRESS SITE PHONE M WITH AREA CODE <br /> Syn S- N Tvo_ 'blud, a69 YA -9q_a-�_ <br /> CITY I STATE ZIP CODE I #OP TANKSAT SITE <br /> CA Ts36 Lt Aj IA- <br /> APPLICANT CONTACT NAME <br /> SU V II-e Sh.L 4 K �V t{Lf LiLL-tel <br /> APPLICANT MAILING ADDRESS APPLICANT P ONE#WITN AREA CODE <br /> (e k u LvL✓1 d�u�— 4bs X 13— (ob3 S <br /> CICTY 1 Sn�iwnnTE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC N <br /> c]OlK Vas I..YT 4�� ot. Cbsure Inst.Won Rpair Retrofit <br /> ACTIVE FACILITY <br /> 2000 2001 2002 2003 2004 2005 <br /> $500 FEE INCLUDES FACILITY FEE*1 TANK <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 ACUPA PROGRAM•$24.001 FACILITY <br /> PERMANENTCLOSURE <br /> emaval or Permitted Closure in Place <br /> TANK IDC s CLOSURE FEE•52791 TANK #TANKS X$279• <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID 4(s): TEMPORARY CLOSURE FEE=$2791 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Corlatmcfion Ins ions <br /> TANK I D tl(s): PLAN CH ECK FEE=57447 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for Inondoring a ui ment.s Ill buckets,tank sumps.mist.) <br /> 7 <br /> PIPING REPAIR FEE 791 FACILITY We for piping,under-dis anser Containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $93/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = 593/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $ON HOUR <br /> ALL FEESARB"SED ON THE S23 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICEREOUEST# I FACILITY ID 1 AMOUNT RECEIVED I CHECKN I RECEIVED IW DATE RECEVED <br /> SR <br /> EH n om(REVISED 02 2m s) <br />