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I. � �r�� ����+� ," rt � � �r a+ .��t����� i ��-r� r� , r + yk r v •e �' iA},��� <br /> r <br /> SAN JQAQUIN COUNTY + 9/1 r <br /> ENVIRONMENTAL HEALTH DEPARTMENT 1( <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Tedephone:(209)468-3420 Fax:(20,9)468-3433 Web:wwwsiov.or�/ehd <br /> v i M� <br /> FACILITY NAME FACILITY CONTACT NAMe <br /> wy <br /> Ot <br /> FACILITY ADDRESS <br /> r SITE ONE#WITH AREA CODE <br /> _ i 1 CITY STATE ZIP CODEe <br /> #OF TANKS AT SITE <br /> CA <br /> { APPLICANT BILLING NAME r <br /> APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY <br /> STATE ZIPCODE ___.CIRC <br /> . LE_WORK TO BE-DONE CONTRACTOR ICC# <br /> . <br /> Closure Installation Re air Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2006-2007) 2006 2007 2008 2009 2010 2011 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2011). <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGF.=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE $375/TANK #TANKS X$375= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ections <br /> TEMPORARY CLOSURE FEE_$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$1,000/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE —$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> S ill buckets sumps,misc. <br /> PIPING REPAIR FEE_$375/FACILITY use for piping,under-dispenser containment,act. $ <br /> MISCELLANEOUS ---- <br /> TRANSFER FEE <br /> CONSULTATION FEE <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $125/HOUR <br /> SAMPLING INSPECTION FEE . <br /> _ $125/HOUR _ $ _. <br /> ALL FEES-ARE BASED-ON THE-$12 i HOURLY RATE TIME'(}dAT EXCEEDS FEES PAID WILL BE FILLED TO APPLICANT. <br /> TOM.AMOUNT DUE <br /> OFFICE USE ONLY $ <br /> SERVICE REQUEST#- FACILITY ID <br /> AMOUNTRECEIVE® CHECK# <br /> RECEIVED BY DATE RECEIVED <br /> Efl3 32(REVISED 0811/11 by KF) <br />