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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.sj og v_or ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> vglero 4t 3(o9 S <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 153 F, lIK'` Si ruk ,20f33� 88 Ir <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> -T CA AS31(a <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> TTLI j o/J �/ Tvt- <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 1-14F— 63( ) 22-7 - '1'7.2 <br /> CITY<AM IA eni'L E C CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Fepalr Retrofit <br /> ACTIVE FACILITY <br /> 2007 2008 2009 2010 20 012 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2007-2008) <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2009-2012) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHAR - TANK <br /> STATE—SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$49.00/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s SURE FEE_$375/TANK #TANKS X$375= <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID TEMPORARY CLOSURE FEE=$375/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <br /> TANK ID#(s): PLAN CHECK FEE_$1000/FACILITY Is <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$3751 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 37f� <br /> spill buckets,sumps,misc. (( JJ <br /> PIPING REPAIR FEE =$375/FACILITY use for piping,under-dispenser containment,act.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $1251 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $125/HOUR $ <br /> SAMPLING INSPECTION FEE = $ 125/HOUR $ <br /> ALL FEES ARE BASED ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ 7? <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED I CHECK# RECEIVED BY I DATE RECEIVED <br /> EH 23 032(REVISED 04/13/12 by KF) <br />