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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPAR <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone. (209)468-3420 Fax. (209)468-3433 Web:www.sieov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 7W) M14WL --QQ - <br /> CITY STATE ZIP C&E I #OF TANKS AT SITE <br /> f!A61-)C# (vmp '-- ?%r <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> &4&t6 X toe- - Je-ss6 964vm6A) <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> A3 7z) ~661z) clp-ae sh-7. * ,q aocO -367 — 0 k60 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> 0 Closure Installation Repai Retrofit 801q6AP IV-r <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK(2004-2007) <br /> $550 FEE INCLUDES FACILITY FEE+I TANK(2008-2009) <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=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$315/TANK #TANKS X$315 <br /> TEMPORARY CLOSURE <br /> �Plan Review and lnsp2ctions) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE $3151 FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE $840/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> cw.4 qd <br /> TANK RETROFIT REPAIR FEE =j�el FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc.) <br /> PIPING REPAIR FEE $315/FACILITY use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE $20 <br /> CONSULTATION FEE $105/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE $105/HOUR <br /> SAMPLING INSPECTION FEE $105/HOUR <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUESTCILITY ID AMOUNTf <br /> RECEIVED CHECK# RECEIVED BY RECEIVEDj <br /> SIR if I <br /> EH 23 032(REVISED 03(20109) <br />