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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT "EIVED <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 FAFC <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sicehd.com <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 6.1;�- Vie_ , -./- i LAG' ALTH <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CO <br /> �76 CP,.� YW ?.ii .`�_ DWO � �EPpPTIVI <br /> CITY I STATE ZIP CODE - OF TANKS AT SITE <br /> CA 11.1 33c) <br /> 95. <br /> APPLICANT BILLING NAME ff APPLICANT CONTACT NAME <br /> /L'jj'✓i7�%2" f'tf1-'— .� /rf[ <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 4-4 7& 3dl-4134 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> E. vet ^' ' Closure nstallation Repair Retrofit <br /> ACTIVE FACILITY <br /> (As of 811/16) $583 FACILITY FEE+$139 PER TANK 2011 2012 2013 2014 2015 2016 <br /> Facility Fee NO LONGER INCLUDES FIRST TANK <br /> (2011-Aug 1,2016)$550 FEE INCLUDES FACILITY FEE+1 TANK $ ff <br /> $130 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=$35.001 FACILITY $ 3�� <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLO $ <br /> SURE FEE_$417!TANK #TANKS X$417= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$417/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1112/FACILITY $f ( 12- <br /> REPAIR <br /> 2REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$417/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets,sumps,misc.) <br /> PIPING REPAIR FEE=$4171 FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $139/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $139/HOUR $ <br /> SAMPLING INSPECTION FEE = $1391 HOUR $ <br /> FEES ARE BASED ON THE$139 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE i cl <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> sp'ot' 3 f.2 02 — GK.µloolp 12221 <br /> EH 23 032(REVISED 07-15-2D161 <br />