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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.sgpy. <br /> FACILITY NAME FACILITY CONTACT NAME <br /> '-paci-4 Pr4el aal(� toc'v mar ju Tk4re= <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> ?61 ( gA ) eA481 <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> l'o CA q 5 z10 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 0 W —foLn V- 1:1 V\�V\J: t' I ®o 1,4 C_ 5004 & ert 04 zam�- Sos-60 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> -Po &)( (o19 4-7 <br /> CITY STATE 23P CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> qa-xCO3-Av vi <br /> A' q�b(06 Clime Iristalla Pain-'�etrof it 0(o 0 4 U <br /> er <br /> ACTIVE FACILITY <br /> 2066 2006 2007 2008 2009 2010 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2004-2007) <br /> $550 FEE INCLUDES FACILITY FEE+I TANK(2008-20`C j <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): --TCLOSURE FEE=$345/TANK #TANKS X$345 <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$345 FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspechons) <br /> TANK ID#(s): PLAN CHECK FEE=$9201 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE $345/FACILITY (use for mnitofirig equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misr-) <br /> PIPING REPAIR FEE $345/FACILITY use for piping,under-disperiser containment ed.) <br /> MISCELLANEOUS <br /> TRANSFER FEE $20 <br /> CONSULTATION FEE 115/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1151 HOUR <br /> SAMPLING INSPECTION FEE $115/HOUR <br /> ALL FEES ARE BASED ON THE$115 MURLY RATE. ThW THAT EXCEEDS FEES PAID VWLL BE BR.LED TO APPLICANT_ <br /> OFFICEUSE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 011000) <br />