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SAN JOAQUIN COUNTY <br /> ENviRoNmENTAL HEALTH DEPARTMEA <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Faze(209)468-3433 Web:www.s ov.or /ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> S e— S F15 t{ <br /> FACILITY ADDRESS -SITEPHONE#VATH AREA CODE <br /> 1000 h*V= L- e- V 2 '367 --'e0® <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> ctA C P CA di5 2,10 5- I(I)v 5 L <br /> APPLICANT—BiLuNG NAME APPLJCANT CONTACT NAME <br /> 5j2p j4 I&A6-Lgy <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 23-7o M N G 6,vz j y" 31x7 — ®0 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> LW,1=' q'�� C ure Installation Repair Retr Bea( --U-- <br /> ACTIVE FACILITY <br /> 2003 20 2005 2006 2007 2008 <br /> FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15 f TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24. FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure inPlace) <br /> TANK ID# s -----=CLOSURE FEE= 15/TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins lions <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$315/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Chedc and Construction Inspections) <br /> TANK ID#(s): N CHECK FEE=$ /FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipenent,cold starts,EVR upgrades, $r3 <br /> s ' ,su <br /> mxclo <br /> PIPING REPAIR FEE _$315/FACILITY (use for piping,u er-disperser containment,ed.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $1051 HOUR <br /> UNAUTHORIZEED RELEASE EVALUATION FEE = $105/HOUR $ <br /> SAMPLING INSPECTION FEE = $1051 HOUR $ <br /> ALL FEES A $105 HOURLY RATE 'nNE THAT EXCEEDS FEES PAM WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID I AMOUNT RECOVED CHBCK# RECEIVED BY DATE RECEWED <br /> S <br /> EH 23 032(REVISED 7M <br />