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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 Fax:(209)468-3433 Web:www.sjgov.org/qhd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> L� 'I4-YaYY� t,wl 4? <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 54 <br /> CITYSTATE ZIP CODE #OF TANKS AT SITE <br /> `f"re ::_ CTA �l lP <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> �orn <br /> r"cl� <br /> L � C Z-- <br /> APPLICANT MAILING AD R S APPLICANT PHONE#WITH AREA CODE <br /> 3&J=/zti (o <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> / _ I ( Rl-[(J Closure Installation poi Retrofit <br /> ACTIVE FACILITY <br /> 2002 2003 2004 2005 2006 2007 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008&New $ <br /> Installs as of 8/1107) <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=$24.00/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 Ins ections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$294/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) $ <br /> TANK ID#(s): PLAN CHECK FEE=$784/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY use for monitoring equipment,s ill buckets,tank sumps,misc.)n�(lf <br /> PIPING REPAIR FEE _$294/FACILITY use for piping.under-dispenser containment,ect.) $��7 <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <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$88 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY IDAMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 0813107( <br />