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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.s1 og v.org <br /> FACILITY NAME FACILITY CONTACT NAME <br /> �_A <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1-"2-,A W . Gtto ea!gs o-fl <br /> CITY I STATE I ZIP CODE I #OF TANKS AT SITE <br /> k's CA S O 1 1 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 41_At— C'_ ..,.v-o r.r�n��v.�.0.3 tae t.c rz� 1(—"tN cam-.o_C_x S�_ - c lr_� <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> k-Zci�)o r A cam- Cz. GLa_ 1_')9__., _ a t m 8 S-8—t O 9 0 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> e_,, \,. -7' l Closure Installation Repair etrofit <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <br /> $500 FEE INCLUDES FACILITY FEE+ K(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 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, $ b <br /> spill buckets,sumps,misc.)Sys <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 I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07101109) <br />