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SAN JOAQUIN COUNTY PAYMENT <br /> ENVIRONMENTAL HEALTH DEPARTMt;_.. RECE YIG <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sj_pov.org/ehd Nov o g 2013 <br /> FACILITY NAME FACILITY CONTACT NAME <br /> r �.1 dmTAL <br /> 0�qz EdAI N�C'c< jjt=Tmw r <br /> FACILITY DRESS SITE PHONE#WITH AREA CODE <br /> Sol N'-I� 34 T94e K d' .ao, S g9• j1 q t <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> 1 oR I CA 1Sib 6 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Kofi Tr4tPl CCA! iK S jerto d Neil,,on <br /> APPLICANT MAILINGADDRESSAPPLICANT PHONE#WITH AREA CODE <br /> S5QT 1-"3 Op. 0 i 1 1/v 371()' dbs Y7 N-P-&S7 <br /> CITY TATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# a� <br /> Iry Closuret Repair Retrofit <br /> ACTIVE FACILITY <br /> 2008 2009 2010 2011 2012 2013 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2008) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009-2013) <br /> $125 PER TANK AFTER FIRST TANK $ l ZS <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <br /> $ <br /> TANK ID#(s): 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 /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1000/FACILITY $�SOS <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <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 /> 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 $Ilv�fb <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVEDORY I DATE RECEIVED <br /> EH 23 032(REVISED 04130113 by RvP) <br />