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I D <br /> SAN JOAQUlN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT O C r 2014 i <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:7wwv&SjcchcFxM [RONImENIAL <br /> HEALT14 <br /> FACILITY NAME FACILITY CONTACT NAME <br /> U.Vb 1� <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> . jps t A--j& <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> -�—eG�L CA J <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME i <br /> WwLblf kju1-Cao—q- <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STA E ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation fmEpa,r jmevolit <br /> ACTIVE FACILITY i <br /> 2009 2010 2011 2012 2013 2014 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK <br /> $130 PER TANK AFTER FIRST TANK $ <br /> $ i <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$151 TANK j <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=S35.001 FACILITY <br /> PERMANENT CLOSURE <br /> Remi nal or Permitted Closure in Place <br /> TANK ID#1(3): CLOSURE FEE=S390 I TANK #TANKS X$390= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEUPORARY CLOSURE FEE_$390 1 FACILITY i <br /> I <br /> INSTALLATION PLAN CHECK <br /> Ian Check and Construction Ins actions <br /> TANK ID#rs): PLAN CHECK FEE_$10401 FACILITY i <br /> 1 <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): ; <br /> $ I <br /> TANK RETROFIT REPAIR FEE _$3901 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spin buckets,sumps,mise. <br /> PIPING REPXR FEE=$3901 FACILITY use for piping,under-dispenser Gcntainmenk act. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $130/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1301 HOUR $ <br /> Is I <br /> SAMPLING INSPECTION FEE _ $1301 HOUR <br /> FEES ARE BASEL]ON THE 5130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE 81LLEn TO APPLICANT, ; <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY <br /> SERVICE REQUEST 3k FACILITYID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECENED <br /> EH 23 D32(REVISED 05-04-14) <br /> 1 <br /> ( <br /> 9'd E9699t?260Z wne10­1Ied elge1le�l e99Z0t'L 60100 <br />