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OCT-25-2010 22:14 From: To:4683433 Paee:6112 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMEN'rALHfALTH DEPARTMICNT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)4683433 Web:www sivov.nr¢/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> I C � P2tJ Cf-'x V Wl+st/\ <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Na CA (P 3 <br /> APPLICANT BILLING NAME. APPLICANT CONTACT NAME <br /> 4v �✓zl till�N e ball <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE I ZIP CODE CIRCLE WORK TO RE DONE CONTRACTOR ICC# <br /> ✓VA�se L, . CL� 4' 3 Cloau Inetaltation Repair Retrain ''C'Lj.Mp, ply <br /> ACTIVE FACILITY '^ <br /> 2005 2006 2007 2008 2009 2010 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2005-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2006-2010) $ <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 COPA PROGRAM =$49,00/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE A 3661 TANK #TANKS X$366' <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ectlons <br /> $ <br /> TANK ID# (s) : TEMPORARY GLOSU RE FEE=$3661 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction inspections) <br /> TANK ID#(s)' PLAN CHECK FEE=$976/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =$366/FACILITY (use for monitoring equipment,Cold starts.EVR upgrades, <br /> spill buckets,sump5,mise.)✓LO(p <br /> $ <br /> PIPING REPAIR FEE _$366/FACILITY use for pipina.under-dispenser containment.ed. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $25 <br /> $ <br /> CONSULTATION FEE = $122/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $122/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $122/H ) <br /> ALL FEE$ARE BASED ON THE$122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE RILLED 70 APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FAcruTTID I AMOUNT RECEIVED CHECK I RECEIVEDRY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED U121H01 <br />