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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.sjgov.org�ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> �I���' L a :An14r, �lti✓l24'l{ 6f)--e- <br /> FACILITYADDRESS SITE PHONE#WITH AREA CODE <br /> > 1/G � m*fld� /t L <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> 6�0 LIC TO CA <br /> APPLICANT BILLING NAME / APPLICANT CONTACT NAME <br /> APPLICANT MAILING AEYDRESS APPLICANT PHONE#WITH AREA CODE <br /> /09 � ncO f�✓11✓l Sid 7�� � ` 9 i t2_ <br /> CITY /IJ/�-S L STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> / Closure Installation air etroflt <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2006-2007) 2006 2007 2008 70 2011 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2011) <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=549.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE_$366/TANK #TANKS X$366= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$366/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s) : PLAN CHECK FEE_$9761 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$366/FACILITY (use for monitoring $ <br /> spill buckets,sumps,mist. <br /> equipment,cold starts,EVR upgrades, 3 7 E <br /> PIPING REPAIR FEE _$366/FACILITY use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $122/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $122/HOUR $ <br /> SAMPLING INSPECTION FEE = $122/HOUR $ <br /> ALL FEES ARE BASED ON THE$122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 06/3/11 by KF) <br />