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fir/ SAN JOAQUIN COUNTY 11* / \ <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3`"Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(Vh floor):(209)468-3433 Web: www-s'gov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 50E.S TMAN/E-L FLA1A IAc.Wruts,lz 'bµo0T <br /> FACILITY ADDRESS SITE PHONE 0 WITH AREA CODE <br /> lzboo S , }l 4a �aAt i� D 2D9 z }r - z40r <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> L op CA 9S33o L <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ALTIONk EUtrir Ff,rLr•1(,, r_ 04/CNA-F.L <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> SID 102 r yr6 333 - Ilsi <br /> — <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> W • S AtXo C A 9s6 ct QClosure Installation Repair Retrofit SEE A'I-YACfi66 <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 2002 2003 2004 2005 2006 2007 <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <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 /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$285/TANK #TANKS X$285= $ S}O <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): $ <br /> TEMPORARY CLOSURE FEE_$285/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$760/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$285/FACILITY use for monitoring equipment,s ill buckets,tank sumps,misc. $ <br /> PIPING REPAIR FEE _$285/FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $95/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $95/HOUR <br /> SAMPLING INSPECTION FEE _ $95/HOUR <br /> ALL FEES ARE BASED ON THE$95 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECENED <br /> SR <br /> EH 23 032(REVISED 01/29/07) <br />