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� <br /> ENVIRONMENTAL HEALTH DEPARTMENT E <br /> SAN JOAQUIN COUNTY 0 RECF ' <br /> VED <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sicehd.com JAN 17 2018 <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Aj�4 <br /> C17GI&W 5;5-;#2W111? ENVIRONMENTAL, HEALTH <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE r7 N 1 <br /> 795-5Ae111*1 rIP (2192) ft9- <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA 95371P <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> —f—Y, <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 4w 516wf 4WIR-T, lam- r) 3s/-? <br /> 3 <br /> CITY STATE _ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair,,fre-trofi <br /> ACTIVE FACILITY <br /> (As of 8/11/116) $583 FACILITY FEE+$139 PER TANK 2011 2012 2013 2014 2015 2016 <br /> Facility Fee NO LONGER INCLUDES FIRST TANK <br /> (2011-Aug 1,2016)$550 FEE INCLUDES FACILITY FEE+1 TANK $ <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=$417/TANK #TANKS X$417 <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$417/FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1112/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$417/FACILITY (use for monitoring equipment,cold starts,EVIR upgrades, $ SL <br /> spill buckets,sumps,misc.) <br /> PIPING REPAIR FEE=$417/FACILITY use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $139/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $139/HOUR $ <br /> SAMPLING INSPECTION FEE = $139/HOUR $ <br /> FEES ARE BASED ON THE$139 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED To APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 07-15-2016) <br />