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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMA <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax. (209)468-3433 Web:www.sjgov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Jro SAJ11,A' Des �r mj6 A01,/-) <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> f 2;j2o <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Z±Q LL'-4rA) cJ-6_3 �' ). '-�Z-fx <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> 14) C-jfj.�>1+0 Closure -installation g6paip Retrofit 1 000 15 <br /> ACTIVE FACILITY <br /> 2007 2008 2009 2010 2011 2012 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007-2008) <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 /> 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=$375/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 Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1000/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc.) <br /> PIPING REPAIR FEE $375/FACILITY (use for piping,under-dispenser containment,ect.) <br /> \MISCELLANEOUS <br /> T\RAjSFER FEE $25 $ <br /> CONSULTATION FEE = $125/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $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 TO APPLICANT. <br /> TOTAL AMOUNT DUE $s 5 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY 7DATE RECEIVED <br /> EH 23 032(REVISED 04/13/12 by KF) <br />