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`.! SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 F=(209)468-3433 Web:www.sigov.or9-/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> sit <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE aP CODE I #OF TANKS AT SITE <br /> T`Q cX D CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Pr-I RSVIV H%DRi9 L)UCS' J tom^ N TERSON <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 1 G�3 W. AEL. s-EQUNVO -310 2 q-C> <br /> CITY STATE I ZJP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2008 2009 2010 2011 2012 20 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2008) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009-2013) <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=$35.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$375/TANK #TANKS X$375= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$375/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): QT PLAN CHECK FEE=$1000/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$375/FACILITY (use for monitoring equipment,cold starts.EVR upgrades, <br /> spill buckets sums misc. <br /> $ <br /> PIPING REPAIR FEE _$375/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 ARR $ <br /> CONSULTATION FEE _ $125/HOUR 10A0WCWR= $ <br /> �L <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 <br /> OFFICE USE ONLY <br /> IF SERVICE REQUBST# I FACILITY 10 AMOUNT RECEIVED CHECK 0 1 RECEIVEDj3Y I DATEECEMED <br />