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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.or /e ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> T ALAa- c)-I <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> Lo S- N. PPe�V�AL ,A,� <br /> CITY STATE ZIP CODE <br /> CODE #OF TANKS AT SITE <br /> STo ',tCv t-& CA 'I S Rz�] <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 6—( C ,, <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> ), Q i <br /> CITY STATE ZIP C DE CIR LE WORK TO BE DONE CONTRACTOR ICC# <br /> _ 1 Closure Installation pair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE« 1 TANK(2004-2007) 2004 2005 2006 2007 2008 2009 <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2008-2009) <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=$49.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$345/TANK #TANKS X$345= $ <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$345/FACILITY - $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections i <br /> TANK ID#(s): PLAN CHECK FEE_$9201 FACILITY ' $ <br /> 1 14 <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$345/FACILITY (use for monitoring equipment,cold starts.EVR upgrades, <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE _$345/FACILITY (use for pipin2,under-dispenser containment,ect. $�"t <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $ 115/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $ 115/HOUR $ <br /> SAMPLING INSPECTION FEE = $ 115/HOUR $ <br /> ALL FEES ARE BASED ON THE$115 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07/01/09) <br />