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�� � LI �� u .�D <br /> ' � SAN JoAQiruv COUNTY l� � � \�J, y <br /> ENVIRONMENTAL HEALTH DEPAR <br /> 304 East Weber Avenue,3"Floor,Stockton,CA 95202-270>F'EB 2 2 N06 <br /> Tefephone:(209)468-3420 Fax(Pfloor):(209)468-3433 Web:www.sjgov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAM <br /> �nj"FNr HF <br /> FACILITY ADDRESS - SITE PHONE#WITH AREA CODE <br /> ow w) K�1 a9 clo �>&a-Aq q o <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> m CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> mvig *nara �AIwk OU \0-8n /�RgW '1 nSgr' <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> /-P, 0. box q33 qlla 391 -438b <br /> CITY l STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 2000 2001 2002 2003 2004 2005 <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED $ <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 /> TANKID# s CLOSURE FEE=$279/TANK #TANKSX$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,spill buckets,tank sumps,misc. "6 /l/ <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,ec. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR $ <br /> SAMPLING INSPECTION FEE = $93/HOUR $ <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02/22105) <br />