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v SAN JOAQUIN COUNTY <br /> e { ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone.,(209)468-3420 Fax:(209)468-3433 Web:www-SiRov.or ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> LU �1 ICl 4's In • :F—vx i. a----P iE:�> "6 ct,11 u w M iA L <br /> FACILITY ADDRESS '• ,, SITE PHONE#WITH AREA CODE <br /> CITYSTATE ZIP CODE I #OF TANKS AT SITE <br /> CA c1 S3-?5 (.e <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2003 20 2005 2W6 2007 2008 <br /> $500 FEE-1`f4'CLUDES FACILJ FEE+1 TANK(20 -2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK 08) <br /> $125 PER TANK AFT FIRST TANK r' $ <br /> • if <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 ( ttir1.�.1en PQ`,yTr <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$294/TANK #TANKS X$294= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s) : TEMPORARY CLOSURE FEE=$294/FACILITY $ <br /> STALLATION PLACHECK <br /> IPan Chf ad <br /> Construction Inspections) Co lc-1 54-Cx.if 1- eTafz-- evl/ - - <br /> TANK ID#(s): PLAN CHECK FEE=$784/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE -$294l FACILITY (use for monitor#fg equipment,cold starts,EVR upgrades, $Qr <br /> spill buckets,sumps,misc.)`T <br /> PIPING REPAIR FEE _$294/FACILITY use:for piping,under-dispenser containment,ed. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE = $98/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR $ <br /> SAMPLING INSPECTION FEE = $98/HOUR $ <br /> ALL FEES ARE BASED ON THE$96 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 12/31/07) <br />