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= .�-.»-::.i v -r r , ! . !' r r !► '„'i r�y l� x���j 1°`/-.i+`,.► ► ►! r ► f f'r b ►P..0 <br /> I <br /> J ' SAN J9AQUIN COUNTY ,ay.1C? <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 { <br /> ' Telephone:(7.09)468-3420 Fax:.(20�)468-3433 Web www,sjgov.org/ehd <br /> i FACILITY NAME FACILITY CONTACT NAME 1 <br /> Qh <br /> FACILITY ADDRESS SITE PHONE i6TH AREA CODE ' <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE ! <br /> I " ' I CA <br /> 1 <br /> ' �' t <br /> w r <br /> APPLICANT BILLING NAME _ APPLICANT CQMTACT NAME. ._ <br /> AN j <br /> APPLICANT MAILING ADDRESS APPL CANT PHONE#WITH AREA CODE <br /> . J <br /> CITY STATE ZIP CODE _CIRCLE WORK T -B -DONE ----- _CONTRACTOR ICC—#_— — <br /> Closure Installation Re Ir Retrofit <br /> ACTIVE FACILITY <br /> 2006 2007 2008 2009 2010 2011 <br /> I <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2006-2007) <br /> $550 PEE INCLUDES FACILITY FEE+1 TANK(2008-2011) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGF,=$151 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 $375/TANK #TANKS X$375= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$1,0001 FACILITY $----- <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> --- TANK RETROFIT REPAIR FEE —$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill,buckets,sums misc. <br /> PIPING REPAIR'FEE_$375/FACILITY use forpiping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> ---CtNSULTAT)ON FEE $1Y5/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $125/HOUR $ <br /> SAMPLING INSPECTION:FEE _ $125/HOUR $ <br /> ALL FEES-ARE BASED ON THE$120 HOURLY-RATE;-TIME-'rHAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL,AMOUNT DUE $ <br /> -OFFICE USE ONLY <br /> ..... <br /> ..SERVICE.RE4UEST# - FACIL-ITY'ID'----'--------''AMOUNT RECEIVED CHECK# I RECEIVED BY DATE RECEIVED <br /> EH 23 032REVISED 0814111 by KF) <br />