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SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(rfloor):(209)468-3433 Web:www.sjizov.or /g ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Lt S A Pe-fro teitgin.- IRo a fl c►cc n <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY L STATE ZIP CODE #OF TANKS AT SITE <br /> c, k <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ('en Ir e- � re leu wt--- u4 h leen 9-pits) k-C(,:,-) <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> /7& &)L/© i, I <br /> l��Zt Siree 7` S"I �f 1p�' V D lP C) <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> k?u s a t) �C C� 9 ys_it <br /> Closure Installatio Re ay..Retrofit �ZS�c� � <br /> ACTIVE FACILITY <br /> 2000 2001 2002 2003 2004 2005 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$15/TANK <br /> $ <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=$279/TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE=$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> $ <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) <br /> $ <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = $93/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE = $93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY 11 DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02/22/05) <br />