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S.ANJOAQUIN COUNT), <br /> FN iRoNmE NTAL HFuLTa DIEPARn E[QT <br /> 1868 E.HazekoiiA7ve.. Stockton.C.k 95205-6232 <br /> Telephow: (209)=468-3=420 Fay:(2209)=468-34.3a TTeL:�an���.st>;o�.rn>;elicl <br /> FACILITY NAME FACILITY CONTACT NAME <br /> rco � PrY� R ,2cu l l <br /> FACILITY ADDRESS SITE P NE#WITH AREA CODE <br /> S� O, \)alV CO ST2-9 <br /> CITY STATE ZIP-CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT ILLING NAME APPLICANT CONTACT NAME <br /> aU c e �_ o' R q' <br /> APPLICANT MAILING ADDRESS APPLICART PHONE#WITH AREA CODE <br /> a 5' g --7 10 <br /> CITY_ STATE ZIP CODE I CIRCLE w^RK TO BE DONE CONTRACTOR ICC# <br /> Clo ur Xnsta4lanon Repair Retrofit ( ► <br /> ACTIVE FACILITY <br /> 2008 2009 2010 `'011 2012 2013 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2007-2008) <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2009-2012) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED I $ <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.001 FACIL ffY <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <br /> TANK ID# s n CLOSURE FEE=$375/TANK #TANKS X$375 <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) e ^t <br /> TANK ID#(s) : ( 0�2 60 <br /> W <br /> �� Zb T APORARY CLOSURE FEE=$375 i FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections)_ .__ _...._. <br /> TANK ID#(s) : PLAN CHECK FEE=$1000 i FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE _$375/FACL rrY (use for monitoring equipmert,cold starts,EVR upgrades, <br /> spill buckets sumps,mist. <br /> PIPING REPAIR FEE _$375/FACILITY (use for pipin ,under-dispenser cortainmert,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $125/HOUR $ <br /> UNAUTHORIZED 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 REQUEST= FACILITY ID AMOUNT RECEIVED CHECK= RECEIVED BY DATE RECEIVED <br />