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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.sj oe v.org ehd <br /> FACILITY NAME n / FACILITY CONTACT NAME <br /> Ua( vekcy <br /> CIr4,$cl� <br /> FACILIPY ADDRESS SITE PHONE#WITH AREA CODE <br /> 3 (a-dy) 2F3 -2743 <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> 5 1 CA I 9Sz0I <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> va(( �yL C( of ik� El b <br /> APPLICANT AIL NG ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 191 K jZgkti t- Lj'eCkvck�- 207 f S 3 - 27 �i <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> GjdC- Z p(y Closure Installatio ep r Retrofit o%4 03 <br /> ACTIVE FACILITY <br /> 2005 2006 2007 2008 2009 2010 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2005-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2010) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$15/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.001 FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$366/TANK #TANKS X$366= <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$366/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE=$9761 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK RETROFIT REPAIR FEE =$366/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 3�� <br /> s ill buckets,sumps,misc. <br /> $ <br /> PIPING REPAIR FEE _$366/FACILITY use for piping,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $25 <br /> $ <br /> CONSULTATION FEE = $122/HOUR <br /> $ <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# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07121/10) <br />