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f <br /> SAN JOAQUIN COUNTY <br /> r ENVIRONMENTAL HEALTH DEPARTME <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.$)gov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> AI r ' <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> (725 <br /> CITY STATE ZIP CODE �[ #OF TANKS AT SITE <br /> G/G CA '7 5� T <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Gr�.✓i � � � NO <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 6-g-7 7`?- ©S-:-C <br /> CITY STATE f ZIP CODE CIRCLE WORK TO BE DONE I CONTRACTOR ICC# <br /> �e�iivyT( 9¢Sq� Closure Installation(ER) Retrofit 5ZS-ZZ4 V <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2004-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2009) <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=$345/TANK #TANKS X$345= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$345/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$920/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$345/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE =$345/FACILITY use for piping,under-dispenser containment,ect.) $ 3 4 <br /> 15, <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $115/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $115/HOUR <br /> SAMPLING INSPECTION FEE = $115/HOUR $ <br /> ALL FEES ARE BASED ON THE$115 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07/01/09) <br />