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S #� 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 2ov.orvjrehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> /4T4'Tf:bu'I I' (UF-o42 : ega'so+n <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> IJ. San gL_ ItIi 402--2-4co <br /> CITYI STATE ZIP CODE I #OF TANKS AT SITE <br /> S�C.k6D,-, CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Ci�Y'i S rain 15i-m kc kc. ,bm&re 1m s-gau Vt-- <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 113-4 ,�- M�7dux,P,Q Blt�. FIs-r6�o <br /> CITY 1lnSTATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> F�l �m ��- Closure Installatio epair etrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(20042007) 2004 2005 2006 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=$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM X49.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE=$3451 TANK #TANKS X$345= $ � <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspectionsl <br /> TANK ID#(s): I TEMPORARY CLOSURE FEE_$3451 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$9201 FACILITY <br /> REPAIR PLAN CHECK <br /> TANKID#(s): <br /> $ <br /> TANK RETROFIT REPAIR FEE =$3451 FACILITY (use far monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc.)PIPING REPAIR FEE _$3451 FACILITY use for piping,under-dispenser containment,ect. $ 345— <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $1151 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1151 HOUR <br /> SAMPLING INSPECTION FEE = $1151 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# I FACILITY ED I AMOUNT RECEIVED I CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07101109) <br />