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SAN JOAQUIN COUNTY <br /> ENviRoNmENTAL HEALTH DEPARTMENT* <br /> 600 East Main Street Stockton,CA 95202-3029 <br /> Telephoner(209)468-3420 Far.(209)468-3433 Web:wwww.s <br /> jgo v.orWehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE- <br /> i C Opr-�-To ro <br /> 1201 ) 36-7 <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> CA 4111OW TO <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 2: <br /> Z(�GLJCY 90-jFZPLX 5 1- -2050"x)� <br /> APPLICANT MAILING ADDRESS APPLICATP E#WWTH AREA CODE <br /> 737o vv%o-(.6= ( 367 <br /> CITY STATE !ZIPCODE CIRCLE WORK TO BE DONE_ I CON TRACTORICC# <br /> L—oz -i-- I- CL4 C Installation Repair Retrofit 01 2 UT <br /> ACTIVE FACILITY <br /> 2003 2004 2005 2 2007 2008 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+I TANK(2008; <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 CUIPA PROGRAM=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> [Removal or Per Closure in Place) <br /> TANK ID 9(sj: CLSURE FEE=$31:5=ITA=NK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$3151 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): N CHECK FEE=$840/FACILITY $ <br /> REPAIRPLANCHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for fronitoring equ4mort,cold starts,EVR upgrades, $ <br /> S 'll buckets,surrq)s,rrdsc.) <br /> PIPING REPAIR FEE $315/FACILITY (use for piping,uriderAispermer contain ient,act.) $31Sa) <br /> MISCELLANEOUS <br /> TRANSFER FEE $20 $ <br /> CONSULTATION FEE = $105f HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1051 HOUR $ <br /> SAMPLING INSPECTION FEE = $1051 HOUR $ <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID VALL BE BILLED TO APPLICANT <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECERIED -CHBCK# BY DATE RECEIVED <br /> SR I I I <br /> EH m on(RISAM 7118" <br />