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JAN-16-2009 15:56 Service Station Systems 408 938 8888 P.04 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALT14 DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www,sieQY,org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> L"So 1 rs- ® A y E LtiJ <br /> FACILITY ADDRESS SITE PHONE N WITH AREA CODE <br /> rlo- <br /> -3ig -- 3l <br /> CITY STATE ZiP CODE 1 #OF TANKS AT SITE <br /> CA S g a9 L;l 1 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE 0 WITH AREA CODE <br /> 93&- 7//3 <br /> CRY STATE ZIP CODE CIRCLE WORK TO 9E DONE CONTRACTOR ICC# <br /> - �` -)1 a Closure Installation ep� Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2002-2007) 2003 2004 2005 12006 2007 2008 <br /> $550 FEE INCLUDES FACILITY FEE+ t 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=$24,00/FACILITY $ <br /> PERMANENTCLOSURE <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 Inspections) <br /> TANK ID#(5). TEMPORARY CLOSURE FEE-$294 1 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s); PLAN CHECK FEE_$784/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,sums misc. 31�. <br /> PIPING REPAIR FEE = 4/FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = $20 $ <br /> CONSULTATION FEE $98/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 981 HOUR $ <br /> SAMPLING INSPECTION FEE = $98/HOUR $ <br /> ALL FEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE 611-1-0 TO APPLICANT, <br /> OFFICE USE ONLY <br /> ff <br /> ICE REQUEST✓! FACILITYID AMOUNT RECEIVEDECK8 RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 12131107) <br />