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i 3 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 FACILITY CONTACT NAME <br /> t0 cv,c CGnler fn:ckII L� <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> yavo west Ione 209 60 70 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> s -rocKten CA CIS-.2 d y 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Ge+iler- �yun Inc. candy Orcwn <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 6747 S;err , Court Scl;tc 3 ( 91bV6 6 2a' <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> D v61: C <br /> n ��'• 7 V 96 8 Closure Installation Re air Retrofit S?,5,2010—L1 <br /> ACTIVE FACILITY <br /> 6 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2004-2007) 2004 2005 2002007 2008 1 2009 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2009) $ <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 COPA PROGRAM=$49.00/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$345/TANK #TANKS X$345= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$345/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$920/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): p; I SP,'1i Colt Conk# A 7 <br /> TANK RETROFIT REPAIR FEE 345 ACILITY (usefor monitoring equipment,cold starts,EVR upgrades, 34s all, <br /> I <br /> bucks s sumps,misc. <br /> PIPING REPAIR FEE _$345/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $115/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $115/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $115/HOUR <br /> ALL FEES ARE BASED ON THE$115 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED I CHECK# RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07/01/09) <br />