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SAN JOAQUIN COUNTY HEGb -*vt1- L' <br /> ENVIRONMENTAL HEALTH DEPARTMEN. <br /> 1868 E.Hazelton Ave., Stockton,CA 95205-6232 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orp-/ehd MAR 0 2 2010 <br /> FACILITY NAME FACILITY CONTACT NAME -- ENVIRO j YENTA`i <br /> 6,-?1V7 &fe jA)j)d jj 5Cd// HEA)TIP <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA 5'zd5 ,/) <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> CCS -5 ZG i I��.J 56e17-';7- <br /> APPLICANT <br /> CO//-APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE I ZIP CODE CLE WORK TO BE DONE CONTRACTOR ICC# <br /> C C d Closur22 Installation Repair Retrofit C <br /> ACTIVE FACILITY <br /> 2008 2009 2010 2011 2012 2013 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007-2008) 26)1 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009-2012) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> 3 70 <br /> TANK ID#(s): CLOSURE FEE=$375/TANK #TANKS X$3�5= <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=$1000/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,sumps,misc. <br /> $ <br /> PIPING REPAIR FEE _$375/FACILITY use for piping,under-dispenser containment,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 $-39Q <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 1/16/2013 by KF) \ <br />