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RECHP D <br /> SAN JOAQUIN COUNTY VAR 14 2016 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave.,Stockton,CA 95205-6232 _ <br /> Telephone:(209)468-3420 Fax:(209)X168-3433 Web:www.5' ov.ur le11d ENVIRONMENT iL <br /> �'h 1 TI 1 r•5 r=r]l��s{I`il t-1�1T <br /> FACILITY NAME FACILITY CONTACT AME <br /> civ AV& 5 IM, 0 WAl <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> MVj L W "v-I->✓l c. W 10i 1j - `1,nL z <br /> CITY STATE XIP CODE —#OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONT CT NAME <br /> n <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> -DU' 3 cq/& ,��l I .2s�0 <br /> CITY STATE XIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Kepairpetrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+9 TANK(2007-2008) 2008 2009 2010 2011 2012 2013 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009-2012) — <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=$35.00!FACILITY J $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s CLOSURE FEE_$3751 TANK Lh TANKS X$375= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$375 1 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <br /> TANK ID#(s): PLAN CHECK FEE=$1000 1 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK 10#(s) <br /> TANK RETROFIT REPAIR FEE ;SM 1 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sum s,mist.`• <br /> PIPING REPAIR FEE =$375 1 FACILITYuse(or piping,under-disperser containment,ect) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE _ $125!HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1251 HOUR $ <br /> SAMPLING INSPECTION FEE = $1251 HOUR $ <br /> ALL FEES ARE BASED ON THE 5125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST 9 FACILITY ID AMOUNT RECEIVED I CHECK 9 RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 1/1612093 by KF) <br />