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�. SAN JOAQUIN COUNTY _/ <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Mein Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orlt/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> irc'le h <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> I1o470 Ca -ytbrij 5' <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> La-+kro ICA 330 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> I a,nd Pe6-olev DvS+trT CoI � <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#VVITH44J CODE <br /> 7 470 SVL_ C'v 9cq 2 7 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CON/TRR ACTOR ICC# <br /> V I GrUfvl I l� / �A 2'1) C� S Closure Installation epair etrofR 5Z to 3l q 7 <br /> ACTIVE FACILITY 1,l,� <br /> 00 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2005-2007) 2 5 2006 2007 2008 2009 1 2010 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2010) <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 ACUPA PROGRAM=$49.00/FACILITY Is <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK IDR s CLOSURE FEE=$366/TANK #TANKS X$366= <br /> TEMPORARYCLOSURE <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 i(s): PLAN CHECK FEE_$976/FACILITY <br /> REPAIR PLAN CHECK <br /> TANKID#(s): / <br /> TANK RETROFIT REPAIR FEE =$366/FACILITY (use for nwn0oring equipment,cold starts,EVR upgrades, <br /> spill buckets,surnps,mist.) // <br /> PIPING REPAIR FEE _$3661 FACILITY Iuse for piping,under-dispenser containment,act. $3(0 to <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 <br /> CONSULTATION FEE = E 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 /> OFFICE USE ONLY <br /> SERVICE REQUEST R I FACILITY ID I AMOUNT RECEIVED I CHECK R I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07/21/10) <br />