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03/25/2010 THU 13, 33 FAX 2094663433 STC EHD 0005/005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL IIEAL'I'Ii DEPARTMENT' <br /> 600 East Main Strect,Stockton,CA 95202-3029 <br /> ' Telephone:(209)468-3420 lax:(209)468-3433 ff/cb:.www.sjggy,..Qrg/plld <br /> FACILITY NAME FACILITY CONTACT NAME <br /> VILCAG�:- W�:sT ropalN CuF� <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> 12�� C,k"�N� CA g 5a 1 a <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> L� (-&00 CQnnCzfl C • X nl(✓t) <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> p�V� . oq - --?- g31) W <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> C �S X5301 Closure Installation Repai Retrofit Lf�a 0 B <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2004-2007) 2005 2006 2007 2008 2009 2010 <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 Its : 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 =$345/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <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 I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01/05/10) <br />