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• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3`d Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(5`"floor):(209)468-3433 Web:www.sigov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> R S4E- (, L <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> '4 }0 (0 VkO&IF_ 1, A-"A�) CT- <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Q C(( 1-014 CA 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 1JAi i 014 arc C.l � EE2c�c�, �cC . k14 (CWA-EL W ACT10 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> P 0, 6o X X02 Y- ql6 -�; ;,;s — ! ( SZ- <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> U S _O C A Cf S-b ci ( Closure Installatio epair etrofit S E E- A I- r�� <br /> r <br /> ACTIVE FACILITY <br /> 2001 2002 2003 2004 2005 2006 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <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=$285/TANK #TANKS X$285= <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ections $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$285/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) $ <br /> TANK ID#(s): PLAN CHECK FEE=$760/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $ <br /> TANK RETROFIT REPAIR FEE =$285/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) 4 <br /> 0 <br /> PIPING REPAIR FEE _$285/FACILITY use for pi in ,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $95/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $95/HOUR $ <br /> SAMPLING INSPECTION FEE _ $95/HOUR <br /> ALL FEES ARE BASED ON THE$96 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID <br /> 'RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07128/06) <br />