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i <br /> 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 ov.or /gehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 01 MOP tf j <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> t 1 <br /> CITY STATE ZIP CODE01 1 #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING <br /> 1,NAME APPLICANT CONTACT NAME <br /> `NT <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 25 5 w 1(aw rn C, 5 O U-4.)n <br /> CITYbN <br /> �" <br /> STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation it 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+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 COPA PROGRAM=$49.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE $375/TANK #TANKS X$375= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ctions <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1,000/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> - -- -- $ <br /> TANK RETROFIT REPAIR FEE -$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> s ill buckets,sum s,misc. s <br /> PIPING REPAIR FEE_$375/FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 <br /> CONSULTATION FEE = $125/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $125/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $125/HOUR $ <br /> ALL FEES-ARE BASED ON THE$125 HOURLY RATE: TIME-THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID Al <br /> lIOUNT RECEIVED CHECK# <br /> RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 08/1/11 by KF) <br />