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RECEIVED <br /> t' 7 2014 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> ENVIRONMENTAL HEALTH ENVIR <br /> DEPARTMENT HEALTH IR DEPARTMENT <br /> East Main Street,Stockton.CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:wwwsicov.orzlehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> oln CAT6-c ►rn. Sup r,r-,,`j 0 k t�ALar <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> l,2 l1 (,Z 1 8D-3 -71 57- <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> a V (f C'A- 1 CA 9 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY I STATE 2'1P CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC* <br /> Closure Installation a Ir ,Retrorit <br /> ACTIVE FACILITY <br /> 2007 2006 2009 2010 2011 2012 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007-2008) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009.2012) <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=$49.001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place) <br /> TANK ID# s CLOSUREFEE=$375/TANK #TANKSX$375= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and In ecdorts <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$3751 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 /> ill buckets.sumps,misc. <br /> YD <br /> PIPING REPAIR FEE _$375 1FACILITY use for p1ping,under-dispenser oontainmerrt,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $125(HOUR $ <br /> UNAE THORIZED RELEASE EVALUATION FEE = $1251 HOUR $ <br /> SAMPLING INSPECTION FEE = $1251 HOUR $ <br /> ALL FEES ARE BASED ON THE S126 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT, <br /> TOTAL AMOUNT DUE $ --)r <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILrTY ID MOUNT RECEIVED CHECK It RECEIVED BY I DATER <br /> EH 23 M2 IRE41SE0 04/13112 by KF) <br /> 9'd £9699V960Z Lunelal;ed el9e1le2i 86V:9017 L LZ AeW <br /> L'd £9699b960Z LUnelOJ}ed el9e1le2i 809:9017 L LZ ABN <br />