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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 Fix:(209)468-3433 Web:www___,).s'goy_org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> GLv%v— SroP # /yl�( <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> -4ZWEST ASE <br /> CITY STATE I ZIP CODE #OF TANKS AT SITE <br /> 5Tsci& -von( CA rr5-z ( C 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> W A L Toted ti'fZ rpt l C. <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 'j2• O • T30)C fol f Ct1 33 3— r <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC#G <br /> C A 7 S 6 ct( Closure Installation epair Retrofit <br /> ACTIVE FACILITY <br /> 2002 2003 2004 2005 2006 2007 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <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=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$294/TANK #TANKS X$294= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): —T—TEMPORARY CLOSURE FEE_$294/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$784/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY use for monitoring equipment,s ill buckets,tank sumps,misc.)$Z <br /> PIPING REPAIR FEE _$294/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $98/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $98/HOUR <br /> ALL FEES ARE BASED ON THE$98 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 08/3/07) <br />