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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.sjRov.orjz/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> us A CaN-51 C-1 okkiee— <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> t4blc -iLV- m-7 <br /> I CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> LOCU CA 9JIL16 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> &-ArULik, Si-a--(WO :&15"0; J&�e- 9" WkLi&�Ata 0 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> vcA-0-e— (40% ) -LI-�— (0 0 3 � <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> SeLyL s'e— (ADC Closure Installation(Eep Dw etrofi Roo 14 6 <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2003-2008) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(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=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$315/TANK #TANKS X$315 <br /> TEMPORARY CLOSURE <br /> I (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE $315 FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE $840 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc.) <br /> PIPING REPAIR FEE $315/FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE $20 <br /> CONSULTATION FEE $105/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE $105/HOUR <br /> SAMPLING INSPECTION FEE $ 105/HOUR <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY IDOUNT RECEIVED CHECK# RECEIVED B DATE RECEIVED <br /> SR IDA <br /> EH 23 032(REVISED 02123109) <br />