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0 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjcehd.com <br /> FACILITY NAME FACILITY CONTACT NAME <br /> I-)) <br /> L LE-01-e-i2s <br /> FACILITY AD ESS SITE PHONE#WITH AREA CODE <br /> .t60A6k:-fDIAV-- a(J— O-pq ) Sol C' - L' 14 1 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> j04c-666(i6l C140p, (via. (Jim) OM'ZA&C-S <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> q_S-q!�' LUCAS f2dJCPi(2d- ( 9q ) -230-7206 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTS!ICC# <br /> d I (_#q 1 (117 3Z5 closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK 2010 2011 2012 2013 2014 A015 <br /> $130 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/=/$35.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$390 TA�k #TANKS X$390 <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) z <br /> TANK ID#(s): TEMPORARY CLOS <br /> /OE FEE $390/FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLgN CHECK FEE $1040 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE $390 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buCV ets,sumes,misc.) <br /> 7 3qo <br /> PIPING REPAIR FEE=$390/FACILITY use foriping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $130/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE $130 HOUR $ <br /> SAMPLING INSPECTION FEE = $130/ UR $ <br /> FEES ARE BASED ON THE$130 HOURLY RATE. IME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY In AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 04-22-15) <br />