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ANJOAQUIN COUNTY <br /> ENV1xUNMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone.(209)468-3420 Fax:(209)468-3433 iiib:www.sieov.om/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> . <br /> -NA <br /> a-Y-Fq CH-9-Kr /n!G A So y �1�J 6 bi <br /> FACILITY ADDRESS SITE PHONE N WITH AREA CODE <br /> it 14,01e-fl1 1..i1ZAAa,,,- KIj3('o 6w ,�v�? q65- 019 7 <br /> CITY STATE ZIP CODE #0 F TANKS AT SITE <br /> I<to� CA S2o6 'S,2 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> &M-To 2 ' w&14 )414 sVR :&140H <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE®WITH AREA CODE <br /> z-yzs- SrStA Pi. 60/ 3/z <br /> CITY.9 7p r&-rmf STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC N <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007-2008) 2008 2009 2010 2011 2012 1 2013 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(20032012) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$151 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$35.00!FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE=$375/TANK I #TANKS X$375= <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ecIons <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$375/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins .croons <br /> TANK ID#(s): PLAN CHECK FEE=$1000/FACILITY <br /> REPAIR PLAN CHECK <br /> �f TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$375!FACILITY(use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,mist. <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 EVALUATI ON FEE = $1251 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 Is <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 1/162013 by KF) RECEIVED <br /> AUG 04 2011E <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVI('F,q <br />