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PAYMENT <br /> RECEIVED <br /> SAN JOAQUIN COUNTY 1 2®O9 <br /> ENVIRONMENTAL HEALTH DEPARTMENT JUL <br /> 600 East Main Street,Stockton,CA 95202-3029 SAN JOAOUIN COUNTS' <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.or /g ehd ENVIRONME SENT <br /> HEALTH DEPAR <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 5-r-x— ivy eT-T 4 a L <br /> p8A <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 113? e.b 0—v <br /> CITY I STATE I ZIP CODE #OF TANKS AT SITE <br /> M A"TEC., CA I 9'S 33(r 1 2— <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> LC- Sv Et so <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> -5ee-7 tJ- (�T" ) 44 4 t4 - 1-7 30 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> CA Closur nstallation epair Retrofit 5`LrZ?--7 <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 /> Q' Srj $125 PER TANK AFTER FIRST TANK GjZS $ QZS <br /> TANK PENALTY ASSESSED $ <br /> l / <br /> TANK SURCHARGE=$15/TANK $ �v <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 $$y 0 q <br /> REPAIR PLAN CHECK " <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <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# I FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR 110070-0165-336 -.,a- I `11t (O <br /> EH 23 032(REVISED 03/20109) <br />