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SAN JOAQUIN 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.sj og v.or /> ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> kbi <br /> FACILITY ADDRESS $ITE PHONE#WITH AREA CODE <br /> cC52,1 r <br /> CITYSTATE ZIP CODE #OF TANKS AT SITE <br /> JCA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 25th W 11�W��E7►'... �tcx.�:�`c'1 1' <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ECC# <br /> Closure Installation hijair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2006-2007) 2006 2007 2008 2009 2010 2011 <br /> $550 FEE INCLUDES FACILITY FEE+I 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): y 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 /> -tan Check and Construction Inspections) , <br /> TANK ID#(s): PLAN CHECK FEE_$1,000/FACILITY -_-- ---- <br /> R <br /> ` REPAIR PLAN CHECK <br /> TANK,ID#(s): <br /> ip <br /> TANK RETROFIT REPAIR FEE _$3751 FACILITY (use for monitoring equlpment+cold starts EVR upgrades <br /> spill buckets,sumps,mise. _ _ <br /> PIPING REPAIR FEE_$375/FACILITY (use for piping,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 <br /> i0t�lSULTATION FEE — $125/HOUR <br /> UNAUTHORIZED-kELEASE EVALUATION FEE = $125/HOU42 $ <br /> SAMPLING INSPECTION FEE _ $125/HOUR <br /> .-ALL-FEES-ARE BASED ON THE-5125-HOURLY RATE: TIME-THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> R , <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> of 5" ,. -1'+4 <br /> _ <br /> '-. rx ' <br />