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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> VAOE� RNop <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> // 3 7 w . Lt1 i N2-,n P k)e7 9? L-t - (-D <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> /tAk-r 7— CA 5� <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> VA I,t5,,) -t Aa i SSS Lill't- t? ,73 <br /> CITY SNS STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installatio Re air etrofit I k0Z­ q 7 1 <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2008) 2008 2009 2010 2011 2012 2013 <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2009-2013) <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=$35.00/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 Ins ections <br /> TANK ID#(s) . TEMPORARY CLOSURE FEE=$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1000/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) :_ <br /> TANK RETROFIT REPAIR FEE =$375/FACILITY (use for monitoring equipment,cold starts, EVR upgrades, $ <br /> s ill buckets,sum s,misc. 37.5--- <br /> PIPING REPAIR FEE _$375/FACILITY (use for piping, under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $ 125/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $ 125/HOUR $ <br /> SAMPLING INSPECTION FEE _ $ 125/HOUR $ <br /> ALL FEES ARE BASED ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $37S <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 04/30/13 by RvF) <br />