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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.si2ov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ^R CSO i# Go 80 J/-4-01A t L- <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> es E. Zo 'v'.3. 01-4-4- <br /> CITY <br /> 144CITY STATE ZIP CODE #OF TANKS AT SITE <br /> I�ATH�P <br /> CA v>4-W 3co146 SPLj <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> rawlS Irf R- RY.&a.J , 1 w G . t—% I7C:)'Y Mc ZI,e <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> G?47 Sr,6 R49*16- GT -J 0.6 S S I . -t 5 S 5 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> pVWkLI GA _Q%4eyi Closure stallation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2005 2006 2007 2008 2009 2010 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2005-2007) <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2008-2010) <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=$49.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$366/TANK #TANKS X$366= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$366/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$976/FACILITY $ 7 <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$366/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE _$366/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 <br /> CONSULTATION FEE _ $ 122/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $122/HOUR <br /> SAMPLING INSPECTION FEE _ $122/HOUR <br /> ALL FEES ARE BASED ON THE$122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07/21/10) <br />