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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEi� <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)465-3420 Fax:(209)468-3433 Web:www.sjeov.or¢/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> -eve cLv )J-er (� . .�, . <br /> FACILITY ADDRESS Q SITE PHONE#WITH AREA CODE <br /> Sob W . CVVdeN- zoq Q - 314 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> S-b Acr-) I CA q 53 (o <br /> A PLICANT BIL ING NAME AP CANT CONTACT NAME <br /> 2lro-b e leom rvice Vie• b� a <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> sa l i 2L9 (ooH - g3310 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE I CONTRACTOR ICC# <br /> C)pYdM-e- cj. lens( Closure Installation RepairRetrofit 5D-5)rj 140—UI <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) 2003 2004 2005 20062007 2008 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) <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=$24.001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANKID# s : CLOSURE FEE=$315/TANK #TANKS X 15= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$3151 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(a): PLAN CHECK FEE=$840/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$3151 FACILITY (use for monitoring equipment, starts.EVR upgrades, $ <br /> spill buckets,sumps,misc.) <br /> 3 <br /> 1 5 <br /> PIPING REPAIR FEE _$315/FACILITY use for piping,under-dispenser containment,act.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $105/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $105/HOUR $ <br /> SAMPLING INSPECTION FEE = $1051 HOUR $ <br /> ALL FEES ARE BASED ON THE$98 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL Be BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED I CHECK# i RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 7118/08) <br />