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04/08/2005 14:51 2094E '3 FIFTH FLOOR PAGE 02 <br /> ,ED <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT ApR .� 2005 <br /> 304 East Weber Avenue,3`d Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(5` Jloor):(209)468-3433 Web:www.si ov.or chd AN I0AQU1N COUNTY <br /> NMENTAL <br /> FA'CIU1TY N E FACILITY CONTaF NAME F PR ENT <br /> W � <br /> FA�CIIUTY ADDRESS SITE PHONE 9 WITH AREA CODE q <br /> 1 S r�� � `i(6 3 7 3-� f 1 2 11 — <br /> CITY STATE ZIP CODE I II OF TANKS AT SITE <br /> NCA r i�zz <br /> APPLICANT BILUNG NAME APPLICANT C NTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> OZS� r6 3 -1(3 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC <br /> Closure nstalfatlo Repair Retrofit <br /> ACTIVE FACILITY c �� <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 2000 2001 2002 2003 2004 20 5 <br /> $125 PER TANK AFTER FIRST TANK <br /> f (�25 $ zS <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $1-30 <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A'CUPA PROGRAM X24.001 FACILITY $ <br /> PERMANENT CLOSURE - <br /> Removal or Permitted Closure In Place <br /> TANK ID#(s): I CLOSURE FEE=$2791 TANK I S TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins Dons J� <br /> TANK ID 0(s): PLAN CHECK FEE_$744/FACILITY Y <br /> REPAIR PLAN CHECK PT 'V 13J`70 <br /> TANK ID#(s <br /> TANK RETROFIT REPAIR FEE =$279 1 FACILITY (use for monitoring equipment,svlll buckets,tank sumps,mise $ <br /> PIPING REPAIR FEE =$2791 FACILITY use for piping,undnr-dis nser=ntainment.ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = $20 <br /> CONSULTATION FEE = 5 931 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $931 HOUR $ <br /> SAMPLING INSPECTION FEE = $93/HOUR $ <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUESTS FACILITY ID 7AMOUNT RECEIVED I CHECK It RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02122105) <br />