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• . SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(S`"floor):(209)468-3433 Web:www.sigov.org/ehd <br /> ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Q 'iIV— CT'OP " (372— VQ(Cgh-"_ 4AlL L0 T <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 3 SS-s' , 4 AtMVAaft- Gnl 51to6 3-15`10 CP <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> 5 T G 1.6 T-" CA q S i ( C, 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> P I () - © ?� (0 2 '� 116 3-+ -- ((S'2-'— <br /> CITY <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> WS C A 9 S-6 Ct Closure Installation pair etrofit <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 /> 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 /> 1 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.) $Z <br /> PIPING REPAIR FEE _$285/FACILITY use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $95/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $95/HOUR $ <br /> SAMPLING INSPECTION FEE _ $951 HOUR <br /> ALL FEES ARE BASED ON THE$96 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> I <br /> OFFICE USE ONLY __t <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07128/06) <br />