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• SANSDAQUIN COUNTY • <br /> ENmoNMENTAT.HEALTH DEPARTMENT - <br /> 304 Ea--t Weber Avenue,3"Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(ri7oor):(209)468.3433 Web:WWW-$1L+Ov.orglehd <br /> FCACIILITY NAME FA(/C�1�q1TCCY 1�C1O�N7TAACT NAME <br /> FACILITY ADDRESS ISITE PHONE M WITH AREA CODE <br /> 4+d A bn -Dr A6q S�r9 -0141 <br /> CITY STATE MP CODE t#OF TANKS AT SITE <br /> i CA <br /> APPUCANT BILLING NAME APPLICANT CONTACT NAME <br /> Se v i,c '&q Shim Rw- £itltiuuCl✓1 <br /> APPLICANT MAILING ADDRESS ` APPUCANT PHONE#WITH AREA CODE <br /> 4D (�vi�tN Avg 40 W3 -609' <br /> CITY <br /> '' STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC it <br /> a— Closure Installation Ropal strafit <br /> ACTIVE FACILITY <br /> 2000 2001 2002 2003 2004 1 2005 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK `. <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE-$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM-q7'DO/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Parmltrad Closure in Place <br /> $ <br /> TANKIDP s : CLOSURE FEE=$2791 TANK V.TANKS X$279 <br /> TEMPORARY CLOSURE <br /> Pisn Review and Inspections) <br /> $ <br /> TANK ID 0(s): TEMPORARY CLOSURE FEE=$2791 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Cheek and Contmction Inspections) <br /> PLAN CHECK FEE=$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID;P s ; <br /> TANK RETROFIT REPAIR FEE -$2791 FACILITY use for montaring equipment.s1116uckets,tank sumps,rdw.) <br /> ..� PIPING REPAIR FEE 79!FACILITY- use for piping,urtdendis ansa containment,scO <br /> MISOELLANEOUS <br /> TRANSFER FEE a $20 <br /> $ <br /> CONSULTATION FEE _ $93/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE il= $931 HOUR <br /> $ <br /> SAMPLING INSPECTION FEE = $931 HOUR <br /> ALL FEESARE EASED ON TWE 593 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL HE BILLED TO APPLICANT. ' <br /> OFFICEUSEONLY <br /> 9ERVICEREOUEST# I FACILITY IO I AMOUNTRECE1VE0 CHECXM RECENFA BY DATE RECENED <br /> SR <br /> EH 23=(REVISED PLTSIaS) <br />