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SAN JOAQUw COUNTY (.P <br /> ENVIRONMENTAL hEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA'95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:MMM sil;Ov-or ehd <br /> FACILITY CONTACT NAME <br /> FACILITY NAME -------------- <br /> til I L�uJmlcla:� i <br /> SITE PHONE#WITH AREA CODE <br /> [FjACIL�YARES`SI �p tr5 <br /> p I U,cam #OF TANKS AT SITE <br /> CIN STATE ZIP CODE <br /> - <br /> on CA X15 'YO <br /> APPLICANT BILLING NAME APPLIT NAME <br /> CANT CONTAC <br /> APPLICANT MAILING ADDRESS 4AU"CANT P # <br /> HONE WITH AREA CODE <br /> CIN STATE ZIP GODE CIRCLE WORK TO BE DONE CON�R�T�vOORIC kM U� <br /> -� Closure Installation Repel Retrofit -Iw0 <br /> MCI <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+$125 PER TANK AFTER FIRST TANK 1 TANK(2008-2009) <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE_$15/TANK $ <br /> SU <br /> STATE RCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY <br /> i <br /> - PERMANENT CLOSURE $ <br /> Removal or Permitted Closure in Piace <br /> =:: <br /> CLOSURE FEE_$3151 TANK #TANKS X$315 <br /> TANK ID# s <br /> TEMPORARY CLOSURE _ <br /> tTANK <br /> eview and Ins actions $, <br /> D#(s): TEMPORARY CLOSURE FEE_$315/FACILITY <br /> INSTALLATION PLAN CHECK $ <br /> Plan Check and Construction Ins actions <br /> PLAN CHECK FEE_$840!FACILITY <br /> TANK ID#(s) <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts, <br /> 'VR5 -TANKRETR s ill buckets,sum s,misc. $PIPING REPAIR FEE _$315/.FACILITY (use for pipin ,under-dispenser containmen, <br /> MISCELLANEOUS $ <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $105/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $1051 HOUR $ <br /> SAMPLING INSPECTION FEE _ $105/HOUR <br /> ALL FEES ARE BASED ON THE$106 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY AMOUNT RECEIVED CHECK# RECEIVEDay- I DATE RECEIVED <br /> SERVICE REQUEST# FACILITY ID <br /> 1 , � . <br /> SR <br /> EH 23 032(REVISED 03120109) 74r] V <br />