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Mai ,15 2006 4:41PM We -tern States Contractin 480-491-5847 pa•2 <br />SAN JOAQUIN CUUNTY el <br />3(o <br />py ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue., 3`d Floor, Stockton, CA 95202-2708 <br />Telep.hene: (2.09) 468-3420 Fax (Vh floor): (209) 468-3433 Web: www.sigov.or9' <br />FACILM' NAME <br />FACILITY CONTACT NAME -- <br />Ck t i� JC- QS <br />5 a" s k±`lPac$AAQe- -- — <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE — <br />fltntEjS'g `T�Y16�Z�f lklyf <br />("40T <br />CIT STATE <br />ZIP CODE st OF TANKS, AT RITE <br />-- - <br />-((p CA <br />_T ?aa vmsws+sewn.rwsw+nr <br />APPUC:ANT 131 LUNG NAA�mr-- APPLICANT CONTACT NAME <br />p <br />j p.tI� \ it � as✓r. 1g!> <br />AJPPI-ICANT MAILING ADDRESS APPLICANT PHONE #'AITH AREA CQDE —�-- <br />�.tt-�j� <br />CIT) <br />STATE <br />ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR Ir C 0 <br />E— ?J <br />� L <br />(00m:;5 Closure nstallatlo Repair Reho <br />—__ <br />ACTIVE FACILITY — —� <br />2000 2001 2002 2003 2004 2005 -tel <br />$500 FEE INCLUDES FACILITY FEE+ t TANK <br />$12; -PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED — <br />TANK SURCHARGE = S157TANK <br />STAFE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.001 FACILITY — — <br />I PERMANENT CLOSURE <br />cmcval or Permitted Closure In "face) — <br />TANK ID>f (s) : I CLOSURE FEE - $279 / TANK4! TANKS X $279 =_ <br />TEMPCRARY CLOSURE <br />Flan Rmview and Inspections) <br />TAN',( ID * (s} : <br />-EMPORARY CLOSURE FEE = $279 / FACILITY — <br />EINSIALLOMON PLAN CHECK Clteck and Construcllon Inspectfons) PLAN CHECK FEE = S744 / FACII-17Y <br />REPAID FLAN CHECK <br />TAMS FETROFIT REPAIR FEE - 9,279 / FACILITY (use for monitoring equipment, splq buckets, tank sum s, misc.)- <br />- <br />PIPING REPAIR FEE = $279 i FACILITY (use for piping under -dispenser containment, ecl)— — <br />FAISCEI.LAMEOUS <br />TRANS=ER FEE <br />CONSULTATiON FEE = 7i y;:l Nuux <br />UNAJT-IORIZED RELEASE EVALUATION FEE = $ 931 HOUR — — -- <br />SAMPLING INSPECTION FEE - S 931 HOUR —�-- <br />Ai I FFES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />'.4 G <br />,FF -ICI_ USE ONLY <br />ERVICfi R[QUE3T ri FAGIiffY ID AMOUNT RECEIVED CHECK # R.ECENED BY DATti REf:EIVE_D <br />d ^..� 032 jREVI: ED 0Z122r01i) <br />.CO <br />