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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web. www.sjgov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> A`eI k51� L <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> ;IS-�-7S 5,Pct 4 (d,61 ) J- ..35 - '7'7'7'1 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> ro�-C`� CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 5�. 1 j'�I'i14�C�IIIC% �I'U>1 .S�• ,�1; C �,�Qt� - •��� <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> CA 3� Closure Installation Repay Retrofit <br /> ACTIVE FACILITY <br /> 2002 2003 2004 2005 2006 2007 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2002-2007) <br /> 5550 FEE INCLUDES FACILITY FEE+ 1 TANK(2008&New $ <br /> Installs as of 8/1/07) <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 /> PERMANENT CLOSURE <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 Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$784/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) i <br /> TANK RETROFIT REPAIR FEE _$294/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) � <br /> PIPING REPAIR FEE _$294/FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = S 98/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 98/HOUR <br /> $ <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# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br />