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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 Fier:(209)468-3433 Web:www.._sjgo..v....or�/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> --7(a STA-f 1 c,/J A\irA.- A V— <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 7-!�'7S 60 LllJTRy Cf" 2.e') i3 — 3c7 <br /> CITY STATE ZIP CODE �OF AT SITE <br /> ST6Ck Tca CA I�S�1 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> CW TVA L PC-010 L,�l f Yi S j E v c S C e -T-—1 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> Ll <br /> CITY <br /> ]� �/� � // STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> l U S/k/V /, I � Closure Installation 6ai Retrofit <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 <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.) 34 5 <br /> PIPING REPAIR FEE _$345/FACILITY (use for piping,under-dispenser containment,ect.) <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# I FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR I -i <br /> EH 23 032(REVISED 07/01/09) <br />