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SAN JOAQUIN COUNTY /l!)�(� H <br /> ENVIRONMENTAL HEALTH DEPARTMEN CAU d` <br /> _ -- 600 East Main Street,Stockton,CA-95202-30229 <br /> FACILITY NAME <br /> Teleplroae.-(209)468420 FUe:(209)068-3433-Webi M wkj.¢ov o>a/e6d <br /> - -- - <br /> - FACILITY CONTACT NAME <br /> FACILI I YADDRESS <br /> -- SITE PHONE#WITH AREA CODE <br /> rn �� n I. , <br /> C _STATE _ 3:IP CODE <br /> - OF TANKS ATSITE <br /> CA . <br /> th <br /> APPLICANT BILLING NAME - - APPLICANT CONTACT NAME -- - <br /> EW�aICT) � Nn-) <br /> APPLICANTMAILING ADDRESS- APPLICANT PHONE# ITH AREA CODE <br /> 255 lLlil�l>Jrata-r d¢., s[tx�y�r� <br /> CITY - STATE IF CODE . CIRCLE L`KKOiBE DONE CONTRACTORICc# - <br /> - Clo$ure..anstallatlon._. air,.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 INA CUPA PROGRAM=$49.00/FACILITY $ <br /> - .PERMANENT CLOSURE, -- - - <br /> Removal or Permitted Closure In Place <br /> TANK ID#(a): CLOSURE FEE-$375/TANK #TANKSX$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 Constmceon Inspections) <br /> TANK ID#(a): PLAN CHECK FEE_$1,000./FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE _ <br /> . $375/FACILITY (use for monitoringE�equipment,cold eterts, VR upgrades,. -$ <br /> - - - - - -S III buckets sum a misc. <br /> - PIPING REPAIR FEE=$375/FACILITY use for ellng,untler-dis penser containment,act $ - <br /> MISCELLANEOUS <br /> TRANSFER FEE = $26 $ <br /> -- CONSULTATION FEE _ $-.1257HOUR - - $ <br /> UNAUTHORIZED RELEASE EVAL = $.125/HOUR - - $ - <br /> SAMPLING INSPECTION FEE _ $125/HOUR <br /> ALL FEES ARE BASED ON THE$125 HOURLY RATE. TIME'THAT E%LEEDS $ <br /> FEES PAID WILL BE BILLED 70 APPLICANT. <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY - $ <br /> SERVICE REQUEST# FACILITY IO AMOUNT RECEIVED <br /> CHECK# RECEIVED BY DATE$ECEIVED <br /> EH 23 032(REVISED 08/1H1 by KF) .. <br />