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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.si o8 vorg/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 7G 6Fls S 50Ti0f'J <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 'Z57 7 Pj1 s 2°9 `3 3 13 - ,7-7 7 7 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> �RAcy CA Q5376 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ARP MIN( M6(z- Cc-)RPz)(zI�71o,v HopsNoj-) <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2. 57-15 S, P TTEosori Pis C 4E8 - g5L-3 /'(o - 2-9q - 1219 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> TRAc y CA CtS-376 Closure Installation Repai Retrofit 5 2 5 2 <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2003-2008) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(?UO<3) $ <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=$315/TANK #TANKS X$315= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$315/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$840/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment cold sta EVR upgrades, 31 <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE _$315/FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $105/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $105/HOUR <br /> SAMPLING INSPECTION FEE _ $105/HOUR <br /> ALL FEES ARE BASED ON THE$105 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 /> EH 23 032(REVISED 02/23/09) <br />