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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.sigov.org/ehd <br /> FACILITY NAMEFACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1�G` 'iN • 11A.V h�.� �� <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> )6 1 CA q�5242- 1 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> mi �--M U �''�\/1 AM , SOI) M S Gl,l, <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 1V-i-�0 1 rCA Dv lvr I b F---,L;��/- 1 C9 C <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> kM h O O Y-cA NA CA- cAS 1 42— Closure Installationepair� Retrofit <br /> ACTIVE FACILITY <br /> 2003 2004 2005 2006 2007 2008 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2003) <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=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$315/TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$315/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$840/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets,sumps,mise. <br /> PIPING REPAIR FEE _$315/FACILITY (use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $105/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $105/HOUR $ <br /> SAMPLING INSPECTION FEE = $105/HOUR $ <br /> ALL FEES ARE BASED ON THE$98 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 DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 7/18/08) <br />