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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> / F<t ' 4* C.4=65 .J^w1 k L. If a.e1w"w'-ry <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 405 15. L..O�.►tB•6 ,e.�S . oep 3. O t 44 <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> L.AWTj440je>P CA VIP 6•ail0 I 3CoN6 e.Pw- <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> rowSTIYL.6 R—Ry 4j , I N G . LI CP'[P'V MC IIG6I-.4 7-115 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 4;147 On 55 pyr e. or : a-vie J 026 S g t . -7 Vp 5 5 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> C.e► 01114 Ek Closure s allation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2005-2007) 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#(s): CLOSURE FEE=$366/TANK #TANKS X$366= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$366/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$976/FACILITY $ -`Z Y✓ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): f <br /> TANK RETROFIT REPAIR FEE =$366/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets sumps,misc. <br /> PIPING REPAIR FEE _$366/FACILITY fimp for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 <br /> CONSULTATION FEE _ $122/HOUR EIV D <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $122/HOUR 2 ' 2 10 <br /> SAMPLING INSPECTION FEE _ $1221 HOUR SAN 3 QUIN C NW <br /> ALL FEES ARE BASED ON THE$122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. HEALTH DEPARTMENT <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> ISR,9P $ .,7v !B <br /> EH 23 032(REVISED 07/21/10) <br />