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SAN JOAQVFI COUNTY pAYMENT <br /> ENVIRONMENTAL HEALTH DEPARTMENT* RECEIVED <br /> 304 East Weber Avenue.3`d Floor.Stock-ton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(5'floor):(209)468-3433 Web:NyNvNv.sjgov.org/ehd �Ep �, 7 2005 <br /> FACILITY NAME FACILITY CONTACT NAME COUNTY <br /> / ! ��J �j,� / ENVIRON ENTAL <br /> ZFACVILITYAD <br /> 2p S D /"�Y / /I /YlG4G7 ARTMENT <br /> ESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> 5� �9M CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> /,76. KY <br /> APPLICANT MAILING ADDR SS APPLICANT PHONE#WITH AREA CODE <br /> 51-7 d 1 & his' sib W'/6 <br /> CITY TATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> l�z drlJ�" <br /> ACTIVE FACILITY <br /> 2000 2001 2002 2003 2004 2005 -20 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK <br /> $125 PER TANK AFTER FIRST TANK $ 0 Z3`o-ISS <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> s z3a, <br /> TANK SURCHARGE=$15/TANK q q <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ Z3 1 I <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID# s CLOSURE FEE=$279(TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): �' PLAN CHECK FEE=$744/FACILITY $ <br /> l�563,vo <br /> REPAIR PLAN CHECK <br /> TANK ID# s : $ <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) $ <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR $ <br /> SAMPLING INSPECTION FEE = $93/HOUR <br /> ALL FEES ARE BASED ON THE so HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACIUTY ID AMOUNT RECEIVE CHECK# RECEIVED BY DATE RECEIVED <br /> S <br /> 15 <br /> R l31S- Ry o <br /> EH 23 032(REVISED 02127!05) <br />