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N"/ 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.sigov.org/ehd <br /> FACILITY NAME �+ FACILLIITTY'CONTACT NAME <br /> CµG <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> -377.S'N T.g, Z 7/4167/JJ.f�W <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> vy c CA 1r7-5-'3o Al <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME / <br /> �4 K'v ✓' i1 G k H A/ &e—' <br /> APPLIC NT MAILING ADDR S APPLICANT PHONE#WITH AREA CODE <br /> 30 • t; - Av&S,,7z,J' 4/` PJVS�7i y <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTO ICC# p <br /> eft r t ftl 40 C 4S Closure Installation a Retrofit LS / p <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2006-2007) 06 2007 2008 2009 2010 2011 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2011) 20 <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$375/TANK #TANKS X$375= $ <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1,000/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$375/FACILITY (use for monitoring equipment,void starts,EVR upgrades, $5 T7 <br /> Spill buckets,sumps,misc.) L <br /> PIPING REPAIR FEE=$375/FACILITY use for piping,under-dispenser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $125/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $125/HOUR $ <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 I CHECK# RECEIVED BY I DATE RECEI ED <br /> EH 23 032(REVISED 08/1111 by KF) <br />