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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:\v%vw.siQov.ore/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> S 0,:-4w WL-u ke>_LJ- IRa_Ct-uf <br /> FACILITY ADDRES8 SITE PHONE#WITH AREA CODE <br /> 18 64 w <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA 9 5370 :3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> der-u`(:ce. �-Ecc� sker�s J.-+tc, M �l.Se�-f(�uta <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> lv 6 au�Lkrn .( qd ) _ <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> S C".,— J CjS CA q 5V 3„ Closure Installationpair Retrofit <br /> ACTIVE FACILITY <br /> 2003 2004 2005 2006 2007 2008 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> $ <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_$294/TANK #TANKS X$294= $ <br /> TEMPORARY CLOSURE <br /> Plan.Review.and Ins ections . <br /> TANK ID#(s): _7TEMPORARY CLOSURE FEE_$2'941 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): <br /> $ <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, q <br /> spill buckets,sumps,mist. <br /> $ <br /> PIPING REPAIR FEE _$294/FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $98/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $98/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $98/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 /> EH 23 032(REVISED 12131107) <br />