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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.sigov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FWD 'j, rte, e-�" <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1 25 v�. 1.oeY� �,� `fie 3- 038 <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> CA Ao <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> �IbZ 123' 0 ,41 LP. `on �o,t��encf�e tJ t�C��ddl-ern <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> q.().-bcDrqb3 . q* <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installatio pair etrofit 45315 <br /> ACTIVE FACILITY !l� <br /> 2002 2003 2004 2005 2006 2007 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008&Now $ <br /> Installs as of 811107) <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$294/TANK #TANKS X$294= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$2941 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$784/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY use for monitoring equipment,spill buckets,tank sumps,misc.) <br /> PIPING REPAIR FEE _$294/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE - $98/HOUR <br /> U VALUATION FEE = $98/HOUR $ <br /> SAlkPLAd ECTI = $98/HOUR <br /> ALL FOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> O NLY <br /> SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED CHECK# I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 08/3/07) <br />