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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.jgov:orglehd, <br /> FACILITY NAME FACILITY CONTACT NAME <br /> --76 S- i /J A AQ <br /> FACILITY ADDRESS y SITE PHONE#WITH AREA CODE <br /> Z S't S- 60 L4 /,-(-I P-�� �L Vt JS (2-0,9 ) 933-1`307 <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> l 6G '�a� � CAIS r/p <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ('CA!I eA LC)L.01/1 rill V'6- S C 6 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 1—) � ,' j/ � ® i2; L) few- 4L& C) <br /> CITY ( STATE Z„IPg CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> `r <br /> J ctf Closure Installation QE9i Retrofit <br /> ACTIVE FACILITY <br /> 2004 20006 2007 2008 2009 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2004-2007) <br /> $550 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=$49.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$345/TANK #TANKS X$345= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$345/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$920/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$345/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ f <br /> spill buckets,sumps,misc.) -34'Z? <br /> PIPING REPAIR FEE _$345/FACILITY (use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $115/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $115/HOUR $ <br /> SAMPLING INSPECTION FEE = $115/HOUR $ <br /> ALL FEES ARE BASED ON THE$115 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 /> EH 23 032(REVISED 07/01109) <br />