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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3`d Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Far.(5'4 floor):(209)468-3433 Web:www.sigov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 3300 ( NfF-2L0 0 12� 5-30 1?F S'- 0 '�(a t <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> S -Vo ClLronl, CA 952os- 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> W A f,r" F,�G( KL EC rZ c 4-6 M ( C(d Arm(. W P,(- q <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 'P. 0 , Ba )C <ozs� (6 3 '4-3 - !! S'Z— <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> A G 5-6 Q ( Closure Installation epair' Retrofit SEE. A-M <br /> 7 <br /> ACTIVE FACILITY <br /> 2001 2002 2003 2004 2005 2006 <br /> $500 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=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$285/TANK #TANKS X$285= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$285/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) $ <br /> TANK ID#(s): PLAN CHECK FEE=$760/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $ <br /> TANK RETROFIT REPAIR FEE =$285/FACILITY (use for monitoring equipment,spill buckets,tank sumps,mist.) <br /> PIPING REPAIR FEE _$285/FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> I $ <br /> { CONSULTATION FEE _ $95/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $95/HOUR $ <br /> SAMPLING INSPECTION FEE = $95/HOUR <br /> ALL FEES ARE BASED ON THE$95 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07/28/06) <br />