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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 Far:(209)468-3433 Web:inww--sigov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ce sr STK <br /> FACILITY D RES S SITE PHONE#WITH AREA CODE <br /> I 2o <br /> CIN STATE ZIP CODE <br /> #OF TANKS AT SITE <br /> Szano&l CA l owc <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> C/ T df CCS PH( CrJ <br /> APPLIC NItT M��AIL7)1NG ADeDR/�ESS�I�� APPLICANT P�Hi ONE#WIfT�H-A2RE'AA CODE <br /> Z C. Wim/ C/\ �JY/£r ��GOO� /� l3 J <br /> CITY /' STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> �` per✓ �52 losure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) 2005 2006 2007 1 2008 <br /> $550 FEE INCLUDES FACILITY FEE+i TANK(2008) <br /> S 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=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE=$294/TANK #TANKS X$294= $ <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE_$294/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(a): $ <br /> PLAN CHECK FEE_$784/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets sumps,misc. <br /> PIPING REPAIR FEE _$2941 FACILITY use for piping,under-dis enser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $98/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR $ <br /> SAMPLING INSPECTION FEE = $98/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 I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 12131107) <br />