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SAN JOAQUIN COUNTY <br /> ENvIRONM'FNITAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> FACILITY NAME - FACILITY CONTACT NAME <br /> Quik-atop #076 Dgbbie Markovich <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1030 S. Olive Ave. 1209 1948-6731 <br /> CITY STATE ZIP CODEOF TANKS�ATSITE <br /> kn <br /> LQICA 95215 --':2 <br /> APPLICANT BILLING NAME ................ <br /> APPLICANT CONTACT NAME <br /> Walton Enqineerina. Inc. Vergniga Frei as <br /> APPLICANT MAILING ADDRESS- APPLICANT t'HUNF A WITH AREA CODE <br /> P.O. Box 1025 <br /> CITY STATE ZIP CODE CIRCLE WORK TO DONE CONTRACTOR ICC# <br /> We ja�amentClosure Installation Re air Retrafit <br /> ACTIVE FACILITY — <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007-2008) --2008 —2009 2010 2011 2012 2013 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009-2012) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> I STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A"I IPA PROGRAM=$35-00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place) <br /> 11"r-�"111111uu I-Iosu <br /> TANK ID#(s): CLOSURE FEE=$375:1 TANK #TANKS X$375 <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE $375/FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction <br /> I <br /> TANK ID#(s): PLAN CHECK FEE=$1000/FACILITY eN <br /> REPAIR PLAN CHECK <br /> TANK ID <br /> TANK RETROFIT REPAIR FEE =$375 1 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> s ill buckets,sum s,mise. 375 <br /> j_PIPING REPAIR FEE =$375/FACILITY use for piping,under-dispenser containment,ect') $ <br /> MISCELLANEOUS <br /> TRANSFER FEE $25 $ <br /> CONSULTATION FEE = S 125/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 125/HOUR <br /> SAMPLING INSPECTION FEE = $125/HOUR $ <br /> ALL FEES ARE BASED ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED FT:0A�ppLICANT <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY <br /> AMOUNT RECEIVED CHECK# RECEIVE <br /> I SERVICE REQUEST# FACILITY ID <br /> EH 23 032(REVISED 1/16(2013 by KF) <br />