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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPART-MF,NI~ <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigoy.org/ehd <br /> FACILITY NAME FACILITY CONTACT` fN(A'ME <br /> (Z bC� L cIc� <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 296o WPAMM., Ge)-Al -W6 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> c CA n <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> vIvn h <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> Aornue <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR rrIC��C# <br /> Mt t�U E Closure Installation epai Retrofit Say80J�'tlT <br /> ACTIVE FACILITY <br /> 2002 2006: <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2002-2007) 2003 2004 2005 2007 <br /> $550 FEE INCLUDES FACILITY FEE+ t TANK(2008 8 New <br /> ails as of 8!1107) $ <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=$24.001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place) <br /> TANK ID# s) CLOSURE FEE=$2941 TANK #TANKS X$294= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$294 1 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s) PLAN CHECK FEE_$784 I FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID# s)_ .-.- -- — - <br /> TANK RETROFIT REPAIR FEE =$294 1 FACILITY (use for monitoring equipment,spill buckets,tank sumps, misc.) $ <br /> PIPING REPAIR FEE _$294 I FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $2D <br /> CONSULTATION FEE _ $98!HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S98/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE = $981 HOUR <br /> ALL FEES ARE BASED ON THE$98 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 08!3!07) <br />