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SAN JOAQUIN COiTNTY <br /> ENn-M,aNnmv' .0 HE.ILTH DE AK'n2 NT <br /> 1865 E.Hazelton Ave-Stocictoii, CA 95205-6332 <br /> Tele,phorae: (309) 168-3120 Fay: (209)=168-3.133 ffi,b:wwN17..sjgm-.oi.gie1ic) <br /> FACILITY NAME FACILITY CONTACT NAME <br /> f�rcfl lam E Ac R; e4 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY I STATE ZIP COIDE I #OF TANKS AT SITE <br /> CAIJI <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> CAN L 5 4'0 le- lk* F& <br /> a(- <br /> APPLICANT MAILING ADDRESS APPLICASIT PHONE#WITH AREA CODE <br /> l0 \)aliolcc M 12�S 5 Lr; -7 60 1 <br /> CITY STA:ffT ZIP CODE 1 CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> 6S I Closure Cnstallatioo Repair Retrofit <br /> ACTIVE FACILITY <br /> 2008 2009 2010 2011 2012 2013 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2007-2008) I <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2009-2012) <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=$35.00/FACIL ITY <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <br /> TANK ID# s : I CLOSURE FEE=$375/TANK #TANKS X$375= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s) : I TEMPORARY CLOSURE FEE_$375/FAC IL rr( <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) _ <br /> TANK ID#(s) :0SSol`"1 �t 0 �LlPLAN CHECK FEE=$1000/ FAC ILrrY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) : <br /> TANK RETROFIT REPAIR FEE =$375/FACL rrY (use for monitoring equipment,cold starts,EVR upgrades, ' <br /> spill buckets,sumps,mist.) <br /> PIPING REPAIR FEE _$375/FAC IL ITl' (use for piping,under-dispenser containmeri,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $125/HOUR $ <br /> UNAUTHORLED RELEASE EVALUATION FEE = $125/HOUR $ <br /> SAMPLING INSPECTION FEE = $125/HOUR $ <br /> ALL FEES ARE BASED ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REOUEST= FACILITY ID AMOU14T RECEIVED CHECK:_ RECEIVED BY DATE RECEIVED <br />