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�.. ..i <br /> 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 sisov.ore/ebd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> o $ (oils D LPrjce- �ytHLMar�l <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> t'6C(j9 . HW-1 88) A-1193 <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> L oc��ro�fl <br /> CA t S22_ a �onl�rPr 14 6 S{US� <br /> 1 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> -rjhoOfo KeFIIJINI $ MAtzke I I-ANcr-- ��HLMAI�I <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 19 t oo R I0G-,E WCIO'�A qas G8-I -a-783 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> CON 9 7 25 Closure Installation Re air Retrofit <br /> ACTIVE FACILITY <br /> 2006 2007 2008 2009 2010 2011 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2006-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2011) $ <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=$49.00/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(a): CLOSURE FEE=$375/TANK #TANKS X 375= <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$375/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Conshuction Inspections) <br /> TANK ID#(a): .3 PLAN CHECK FEE=$1,000/FACILITY $3Qoo <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$375/FACILITY (use for monitoring equipment,Cold starts,EVR upgrades, <br /> spill buckets sumps,mist. <br /> $ <br /> PIPING REPAIR FEE=$375/FACILITY use for piping,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $1251 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $125/HOUR $ <br /> SAMPLING INSPECTION FEE _ $125/HOUR $ <br /> ALL FEES ARE BASED ON THE 3126 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE Is <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITYW AMOUNT RECEIVED CHECK# RECEIVED BY I DATE KECENED <br /> EH 23 032(REVISED 0811111 by KF) <br />