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• SAN JOAQLIN COUNTY • <br /> Eh'VFRONDffi-NTAL HEALTH DEP.AP.TMENT <br /> 600 East Main Street,Stocktom CA 95202-3029 <br /> Telephone:(209)465-3420 Fax:(209)465-3433 97eb:arvv ,.sieov.o,;ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> W \.F COt ., -Il'o �- s <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> \\\\ e �� � .� �..� 0\,ya - aLA3S <br /> CITY STATE ZJP CODE I #OF TANKS AT SITE <br /> i,-0C� ` CA CVS 2y0 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> W aA�L' Er. 'tv.acx', <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> -") •0• 3c"x \OSS' �\\b 3-13 - \\lolo <br /> CITY STATE ZJP CODE CIRCLE WORK TO BE DONE CONTPACTOP.ICC# <br /> \,J - lb�G� Closure Installation =pair etront <br /> ACTIVE FACILITY <br /> 1$500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) 2003 2004 2005 2006 2007 2006 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) <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=S24_00/FACILITY <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$294/TANK #TANKS X$294= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspection=_) <br /> TANK ID#(s): I TEMPOPAP.Y CLOSURE FEE=$294!FACILITY <br /> IN <br /> PLAN CHECK <br /> Plan Check and Construction Insoections <br /> TANK ID#(s): PLAN CHECK FEE=$784!FACILITY Is <br /> .REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> 3\s. $ <br /> TANK RETROFIT REPAIR FEE =S2W/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,mist.) <br /> PIPING REPAIR FEE =$294/FACILITY (use for piping,under-dispenser containment.ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = $98/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR $ <br /> SAMPLING INSPECTION FEE = S 98/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 I DATE RECEIVED <br /> .SR. <br /> ~� EH 23 032!REVISED I2131IOT' J \," <br />