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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH UEPARTMEN <br /> 30,+ East Weber Avenue,3i1 Floor, Stockton,CA 952t,--2708 <br /> Telephone:(209)465-3420 Fax(5'/'floor):(209)468-3433 R'eh:wr.wW sJ.gpv.prg'gbd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> /12co PvTN HA <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 3-212 IVCI6:0' e IA (.ZZ)7) 9y1 269LI <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> S TOc1T'i oN ICA S.?o 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> E M E-i?y,AN 11li'G. je>AI/0 Y QQo wi✓ <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> PY7 SIG&A covier be SuirF T yes S3-1 7.sss <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> 0 V 3 L 1,1V C A. Closure Installation epair etrofit <br /> ACTIVE FACILITY <br /> 2001 2002 2003 2004 2005 2006 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK <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=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$285/TANK #TANKS X$285= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$285/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$760/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): 9'I Prod vr- <br /> TANK RETROFIT REPAIR FEE =$285/FACILITY (use for monitoring equipment,s ill buckets,tank sumps,misc.) <br /> PIPING REPAIR FEE =$285/FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $95/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $95 i HOUR $ <br /> SAMPLING INSPECTION FEE _ $951 HOUR $ <br /> ALL FEES ARE BASED ON THE$95 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 j <br /> EH 23 032(REVISED 07/28/06) <br />