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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMNOO <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fra:(209)468-3433 Web:wwwsa&ov org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> - �� I <br /> FACILITY ADDRESS SITE PHONE#WITH AREA C E <br /> in N \AAq?6 - Ir?89 <br /> CITY .L STATE ZIP CODE n #OF TANKS AT SITE <br /> Iron CA q�o2D�0 C <br /> APPLICANT BILLING NAME APPLICANT CONTACT <br /> NT,AC/,T NAME <br /> -?)z' ,vICi ��0n V14V KIAAU�m <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> '�).0 • i ( q)m 3?/_J38a <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Rpair Retrofit _ <br /> ACTIVE FACILITY <br /> 2003 2004 2005 2006 2007 2008 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <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 /> $ <br /> TANK ID# s : CLOSURE FEE=$294/TANK #TANKS X$294= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$294/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(a): PLAN CHECK FEE=$784/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,cold starts, EVR upgrades, <br /> ill buckets,sumps.1i,.I CMix <br /> $ <br /> PIPING REPAIR FEE =$294/FACILITY use for piping,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $98/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $98/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $98/HOUR <br /> ALL FEES ARE BASED ON THE$9B HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# 1 FACILITY ID I AMOUNT RECEIVED CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR <br />