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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTI'I DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468.3433 Web:www.gov.org/e114 <br /> FACILITY NAME FACILITY CONTACT NAME <br /> f r a 1 <W GF- <br /> FACILITY AD ESS SITE PHONE#WITH AREA CODE <br /> Aq 6 Aj D Ij o 'fA E$S 2p x.•152 <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> SSocv CA <br /> kig.Dy <br /> APPLICANT BILLING NAME I APPLICANT CONTACT NAME <br /> 1 I• 1 C Mt <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 21o00 W /0 21 30 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> SAlkY LfMze -) CA C119 5-Y7 Closure Installation Repair Relrofil S[$ ATALAEO CoPli <br /> ACTIVE FACILITY <br /> 2003 2004 2005 2006 2007 2008 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002.2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) <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=$24.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure In Place <br /> TANK ID# s CLOSURE FEE_$2941 TANK #TANKS X$294= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$294/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construcpon Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$784/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> s ill buckets,sum s,mist. <br /> PIPING REPAIR FEE _$294!FACILITY use for ipin ,under-dis enser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $981 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $981 HOUR $ <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 p 1 FACILITY to I AMOUNT RECEIVED I CHECK k I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 12131107) <br />