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l 111: o <br /> • SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> • 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Far(209)468-3433 Web:www sie0v.or /R ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> t) <br /> agog <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> n 2G�1 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA' . <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Fhk2 *0L CU-UOIJLL2 him or f <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE 0 WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> '56 K,k^ � Q Closure Installation Repair tro t <br /> ACTIVE FACILITY 1 <br /> 2003 2004 2005 2006 2007 2008 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED LI <br /> $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$315/TANK #TANKS X$315= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$315/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <br /> TANK ID#(s): PLAN CHECK FEE_$840/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 315 <br /> s ill buckets,sum s,misc. ` <br /> PIPING REPAIR FEE _$315/FACILITY (use for i in ,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $105/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $105/HOUR $ <br /> SAMPLING INSPECTION FEE = $ 105/HOUR <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL 9E.1:ILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 7/18/08) <br />