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• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www sigov.orwehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> i e ore S <br /> FACILITY ADDRESS SITE ONE#WITH AREA CODE <br /> 5 5 Dove <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA q52 — I <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPo <br /> LICANT MAILING Ar s -DDRESS APPLICANT PHONE WITH AREA CODE <br /> 21buo , 1141 617 Q - 9212 <br /> CITY STATE I ZIP CODE CIRCLE WORK T DONE CONTRACTOR ICC# <br /> g 0 Closure Installation Re ai Retrofit <br /> ACTIVE FACILITY <br /> 2007 2008 2009 2010 2011 2012 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007-2008) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009-2012) $ <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=$49.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANKID# s CLOSURE FEE=$3751 #TANKSX$375= <br /> TEMPORARYCLOSURE <br /> Plan Review and Ins ections <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$375/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(a): PLAN CHECK FEE=$1000/FACILITY <br /> REPAIR PLAN CHECK <br /> TANKID#(s): SIO $ <br /> TANK RETROFIT REPAIR FEE =$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> s ill buckets,sum s,mist. F <br /> PIPING REPAIR FEE _$375/FACILITY use for piping,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $25 <br /> $ <br /> CONSULTATION FEE _ $125/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $125/HOUR $ <br /> $ <br /> SAMPLING INSPECTION FEE _ $125/HOUR <br /> ALL FEES ARE BASED ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 04113/12 by KF) <br />