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OWL <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEP- <br /> 600 East Main Street, Stockton,CA 95202-3, <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sj ov.or /,g ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> (�)v pircc 0 -* Oct (-,I- <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 3� 1� � • C-aV1 r0n ' 0A 2�� ��� 1 — � ��y <br /> CITY V STATE ZIP CODE #OF TANKS AT SITE <br /> -`tcr �c �� CA 1 GJ L LI <br /> APPLICANT BILLING NAME ( APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRES9 APPLICANT PHO14E#WITH AREA fPDE <br /> SS2 �1 Cb�nnno ux���.11h rhe ly �SZCoC>3�-Z <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE —CONTRACTOR ICC# <br /> Closure Installation epair Retrofit cfST5("`-u <br /> ACTIVE FACILITY <br /> 2005 2006 2007 2008 2009 2010 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2004-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2010) $ <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 /> PERMANENT CLOSURE <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): <br /> TANK RETROFIT REPAIR FEE /FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc.)4r <br /> PIPING REPAIR FEE _$345/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $ 115/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $ 115/HOUR <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# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> cu;a nii iccvnccn minsmni <br />