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SAN JOAQUIN;COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT ��- <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-1420 Fay: (209) �68-3433 Web: wwwsigov.ore7ehd <br />FACILITY NAME <br />FACILITY CONTACT NA E <br />C <br />� <br />YVA r <br />FACILITY ADDRESS <br />SITE P O <br />HONE # WITH AREA CODE <br />-�c , <br />2011 <br />CITY <br />STATE ZIP CO E #'OF TANKS AT SITE <br />it APPLIC ILLING NAME APPLICANT CONTACT NAME <br />i APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA. CODE, <br />CITY <br />STATE ZIP CODE CIRCLE WORK TOB NE CONTRACTOR ICC # <br />c:; Closurei Installation aair etrofit <br />i <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) <br />$550 FEE INCLUDES FACILITY FEE+ 1 TANK (2008-2011) <br />$125 PER TANK AFTER FIRST TANK <br />2006, <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <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 />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): CLOSURE FEE _ $375 / TANK # TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK <br />ID # (s) : PLAN CHECK FEE _ $1,000 / FACILITY $ <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE _ $375 / FACILITY use for monitorin a uI ment, Cold starts EVR upgrades, <br />spill buckets sumps, mist <br />PIPING REPAIR FEE _ $375 / FACILITY use for i in,under-dispenser containment) <br />ect. <br />MISCELLANEOUS -- <br />TRANSFER FEE _ $ 25 <br />CONSULTATION FEE <br />r _ $ 1251 HOUR.. $ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 125 / HOUR <br />i <br />$ 1251 HOUR <br />D WILL BE BILLED $ <br />SAMPLING INSPECTION FEE <br />ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAI, <br />TO APPLICANT. <br />TOTAL AMOUNT DUE <br />OFFICE USE'ONLY <br />SERVICE RE U <br />Q EST # FACILITY ID AMOUNT RECEIVED '' I <br />I 'CHECK# I <br />ECEIVED $Y DATE RECEIVED � <br />I ! <br />EH23 032 (REVISED 08!1!11 by KF) <br />i <br />I <br />i <br />