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SAN JOAQUIN COUNTY <br />NVIRONMENTAL HEALTH DEPARTMENT <br />304 t Weber Avenue, 3rd Floor, Stockton, CA 95202- 8 <br />Telephone: (209) 468-3420 Fax (5`" floor): (209) 468-3433 Web: www.sjgov.or /g ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />—11 If Ccsc <br />�9�_� <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />2005 <br />t <br />CITY <br />I STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />c <br />CA <br />CAClosure <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />AVe- �.� <br />2002 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PRONE # WITH AREA CODE <br />2005 <br />2006 <br />CITY <br />STAT . <br />ZIP. 600E <br />CIRCLE WORK.TO.BE DONE <br />CONTRACTOR ICG# <br />CAClosure <br />Installation Re ' Retrofit <br />TANK PENALTY ASSESSED <br />Al. i Wt rAGILl 1 T _ <br />TANK ID #s <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID #s <br />CLOSURE FEE = $285 / TANK <br /># TANKS X $285 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s)':''. <br />TEMPORARY CLOSURE FEE _ $285./ FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE .= $285 / FACILITY use for monito m a ui ment, spill buckets, tank sumps, misc. <br />PIPING REPAIR FEE = $285 / FACILITY use for piping, under -dispenser containment, act. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 95/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 95 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 95/ HOUR <br />AI 1 fCGC ACG LACCA A\I 4LlG lte u�..n. v resr s.ee� �...a �..����� �.•�� �..� ...... __ _.. - __ __ _ _ _ <br />$ <br />..-- . ...._ _. ._e_ _.. ..._ a-- ..��..�. .r. r. .....r .. srav r�vvd.+v v dv.v rnav ••1\ - --6 w 1 V MPr LIliA1Y 1. <br />OFFICE USE ONLY <br />