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' 09/09/2009 WED 11:04 FAX 20194683433 SJC RHO Stockton Sery F' , BQ Cc 11008/008 <br /> 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.si o8 v.org/c <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 1\�l1—G <br /> FACILITY AODRE S ITE PHONE M WITH AREA CODE <br /> CITY STATE ZIP CODE OF TANKS AT SITE <br /> 1J CA <br /> APPLICANTAMMOM NAME APPLICANT CONTACT NAME <br /> O K RiY14 1 c <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE M WITH AREA CODE <br /> Po— <br /> CITY STA ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC M <br /> - Closure Inslalla on Repair eVofll <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2004.2007) 2004 2005 2008 2007 2008 2009 <br /> $550 FEE INCLUDES FACILITY FEE.1 TANK(2008.2009) <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=$49.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Cbsure In Place <br /> TANK ID M(a): CLOSURE FEE=$3451 TANK M TANKS X$345= $ <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK IDAt(a): TEMPORARY CLOSURE FEE=$345/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID N(s); PLAN CHECK FEE=$920/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID M(s): <br /> TANK RETROFIT REPAIR FEE =$345/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets sumps.misc. <br /> PIPING REPAIR FEE _$345/FACILITY use for piping,under-dispenser wcl <br /> nteinment e . $ <br /> MISCELLANEOUS <br /> TRANSFER FEE 20 $ <br /> CONSULTATION FEE = $115/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 115/HOUR $ <br /> SAMPLING INSPECTION FEE _ $11S/HOUR $ <br /> ALL FEES ARE BASED ON THE$115 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST p I FACILITY ID I AMOUNT RECEIVED I CHECK M I RECEIVED BY IDATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07191/09) <br />