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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.sjeov.org/eh <br /> FACILITY NAME FACILITY CONTACT NAME <br /> C <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> ]3-0-c- Om bb 9-30- Er-7-79 <br /> CITYSTATE ZIP CODE #OF TANKS AT SITE <br /> Tri C CA '?S -7-7 <br /> APPLII,CcANT BILLING NAME APPLICANT CONTACT NACM�E <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> ► �+3 v"S-es 6-e_ eoaj 01 (� o L(---q 3 0 3 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACT R ICC# <br /> Closure Installation Aepaip 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 CUPA PROGRAM=$49.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE=$375/TANKT #TANKS X$375= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ections <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 /> TANK RETROFIT REPAIR FEE =$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> s ill buckets,sumps,misc.) 3-7sr- <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 $3-75. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK# ECEIVED BY DATE RECEIVED <br />