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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fox:(209)468-3433 Web:www_sjay o g/-�M <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ftclf'C sr > O ! CK L <br /> FACILITY AD ESS SITE PHONE#WITH AREA CODE <br /> 9 D tsR a•151 <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> ST Lkiv CA 2-0 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 6 M1 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2400 W 0 11 3 0 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> SAN,LXAAZ y � g� ' Closure Installation Re air ReOILVoOI $$i L E COP$$ <br /> ACTIVE FACILITY <br /> 2003 2004 2006 2006 2007 2008 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002.2007) <br /> $550 FEE INCLUDES FACILITY FEE+i TANK(2008) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <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_$294 I TANK #TANKS X$294= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE_$294/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$784/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> s ill buckets,sumps.mist. <br /> PIPING REPAIR FEE _$294/FACILITY use for piping,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $98/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $98/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $981 HOUR <br /> ALL FEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST M 1 FACILITY 10 1 AMOUNT RECEIVED I CHECKS I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 12131107) <br />