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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.sgov_or <br /> FACILITY NAME FACILITY CONTACT <br /> CONTACT NAME <br /> �v"z <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 15'DN rl c�cK To►�2 P—A . <br /> CITY <br /> DD STATE ZIP <br /> �CODE #OF TANKS AT SITE <br /> Nt ! <br /> ®ij CA S3<oG <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Cdi�rle� zc- 7�i®mom Co �!i- � /C.6�ii <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> C3l.4.t A-ve 2t3 305--'7/66 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# ) <br /> &4L1re&w` CAa- 2'lq Closure Installation Repair Retrofit <br /> ) <br /> ACTIVE FACILITY <br /> a <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(2008) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> � $ a <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=$294/TANK #TANKS X$294= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$294/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$784/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ e <br /> TANK RETROFIT REPAIR FEE _$294/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR F =$294/FACILITYuse for piping,under-dispenser containment,ect. $29Y <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $98/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR $ <br /> SAMPLING INSPECTION FEE = $98/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 12/31/07) <br />