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low SAN JOAQUIN COUNTY ./ <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3id Floor,Stoeldon,CA 95202-2708 <br /> Telephone:(209)468-3420 Fox(P floor):(209)468-3433 Web:www.sigov-org/chd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> �arLk e. e_n Frgnce4v �sca�a� <br /> FACILITY AD RESS SITE PHONE#WITH AREA CODE <br /> 707 Zr- X0 s4_"*"; 2 7a F/`>'' 627 `> <br /> CITY ISTATE ZIP CODE #OF TANKS AT SITE <br /> /YI 4,1 fe c4 CA ci 5-?�45� <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE 21P CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retro <br /> ACTIVE FACILITY <br /> 2002 2003 2004 2005 2008 2007 <br /> $500 FEE INCLUDES FAgLITY FEE+1 TANK <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE_$15/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=324.001 FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Pelmided Closure in Place <br /> $ <br /> TANKID# s CLOSURE FEE7=$285 I TANK #TANKS X$2855= <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ctions <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$2851 FACILITY <br /> INSTALTION PLAN CHECK <br /> Plan ChocLAk and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$7601 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): �� �� <br /> $ <br /> TANK RETROFIT REPAIR FEE _$2851 FACILITY use for mrIdating ecluipmnt,spill buckets,tank starps,Ilpsc. <br /> $ <br /> PIPING REPAIR FEE _$2851 FACILITY use for ipng,under-d ensar containment act) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $951 HOUR --- - <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $951 HOUR <br /> $ <br /> SAMPLING INSPECTION FEE = S RHO <br /> 5/HOUR <br /> ALL FEES ARE BASED ON THE SBS HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TD APPLICANT. <br /> OFFICE USE ONLY <br /> 11 SERVICE REQUEST 11! FACILITY ID AMOUNTRECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01128107) <br />