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SAN JOAQ UIN 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. og v.or /g ehd, <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Sa vj0agw 4,vC&";ty Ka*itEn#6n 6+r -F Ie*MYgvnt BrLa waec�c� n <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 7000 MLchaei.Ca iUk13Lvd 209 915-2577 <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> FrCantp CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 3a ley E terprCsipw Incl. Jo-�eph.3a&y <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2370 Ma#L0-CLf-de�Suate,4 If 209 367-4800 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> G4 195240 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2006 2007 2008 2009 2010 2011 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2006-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2011 <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=$366/TANK #TANKS X$366= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$366/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$976/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$ /FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $375. <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE _$366/FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $122/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $122/HOUR $ <br /> SAMPLING INSPECTION FEE = $122/HOUR $ <br /> ALL FEES ARE BASED ON THE$122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ 375. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 06/3/11 by KF) <br />